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� CCiRS UST Spilt Bucket SOLUTIONS DELIVEREDlzwa�� 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 T1 :Diesel 2 . Product stored Diesel 3 . Spill bucket capacity 5 Gallons 4, Manufacturer OPW N Single-walled ❑ Single-walled ❑ Single-walled ❑ Single -walled ❑ Single-walled ❑ Single-walled 5. Construction ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled N Hydrostatic ❑ 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 X Product ❑ Product ❑ Product ❑ Product ❑ Product ❑ Product 7. Spill bucket type ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor 8. Liquid and debris removed from spill bucket:* 3 Yes ❑ No ❑ 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,) ? 9 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10. Tank riser cap included in test? 3 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? E Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12. Starting level 13.00" 13 . Test start time 1 :20pm 14. Ending level 13.00" 15. Test end time 2:20pm 16. Test period 1 hour 17. Level Chan e 0 Test results : p Pass ❑ Fail ❑ 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 Garrett Warren name : w! ° Testers name : Date : 1 - 17-2020 Tester's signature : < •. �� ,IF IF I fir S9 v E' F tb 2020 trinr nNi�''iE rAL HCa�LT ,p GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/PressureMydrostatic, ID = Identification