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® CGRS UST Spill Bucket SOLUTIONS DELIVERED Integrity Testing Form Underground Storage Tanks (UST) Program Instructions on Page 3 Purpose: This procedure is to test the leak integrity of single-and double-walled spill buckets.See reverse side for basic hydrostatic testing instructions.Consult PEI/RP1200,Section 6.2 for hydrostatic test method,Section 6.3 for single-walled vacuum test method,and Section 6.4 for double-walled vacuum test method. Testing Information 1. Tank number T6:UNL T7:UNL 2. Product stored Unleaded Unleaded 3. Spill bucket capacity 5 gallons 5 gallons 4. Manufacturer OPW OPW 9 Single-walled 9 Single-walled ❑Single-walled ❑Single-walled ❑Single-walled ❑Single-walled 5. Construction ❑Double-walled ❑Double-walled ❑Double-walled ❑Double-walled ❑Double-walled ❑Double-walled *Hydrostatic @1 Hydrostatic ❑Hydrostatic ❑Hydrostatic ❑Hydrostatic ❑Hydrostatic ❑Vacuum ❑Vacuum ❑Vacuum ❑Vacuum ❑Vacuum ❑Vacuum ❑Single-walled ❑Single-walled ❑Single-walled ❑Single-walled ❑Single-walled ❑Single-walled 6. Testtype ❑Double-walled ❑Double-walled ❑Double-walled ❑Double-walled ❑Double-walled ❑Double-walled 9 Product ❑Product ❑Product ❑Product ❑Product ❑Product 7. Spill bucket type ❑Vapor ❑Vapor ❑vapor ❑Vapor ❑Va or ❑Vapor 8. Liquid and debris removed from spill bucket:" [5 Yes ❑No I]Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No 9. Visual inspection (No cracks,loose parts or separation of the bucket from the fill pipe.)? 19 Pass ❑Fail ©Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail 10. Tank riser cap included in test? 0 Yes ❑No❑NA [!)Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA 11. Is drain valve included in test? B Yes ❑No❑NA [9 Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA ❑Yes ❑No❑NA 12. Starting level 11.25' 11.50" 13. Test start time 8:20 am 8:20 am 14. Ending level 11.25' 11.50" 15. Test end time 9:20 am 9:20 am 16. Test period 1 hour i hour 17. Level chan e 0 0 Test results: p. Pass ❑Fail 9 Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail Pass/fail criteria:Must pass visual inspection.Hydrostatic:Water level drop of less than 1/8 inch;Vacuum single-walled only; Maintain at least 26 inches water column;Vacuum double-walled,maintain at least 12 inches water column. Comments: *All liquids and debris must be disposed of properly. Testing company �'. CGRS name: Tester's name: Garrett Warren Date . 01/14/2020 Tester's signature: GPH=Gallons per hour,Y=Yes,N=No,NA=Not applicable,VPH=Vacuum/PressurefHydrostatic,ID=Identification