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CGRS UST Spill Bucket SOLUTIONS OELIVEREO • • 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 :87 T2:91 2. Product stored Unleaded Unleaded 3. Spill bucket capacity 5 gallons 5 gallons 4. Manufacturer OPW OPW ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled 5. Construction N Double-walled X Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled 0 Hydrostatic i] Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled 6. Test t e ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled E Product ❑O Product ❑ Product ❑ Product ❑ Product ❑ Product 7. Sill bucket type ❑ Vapor ❑ vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor 8. Liquid and debris removed from spill bucket: ` 3 Yes ❑ No O 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.)? N Pass ❑ Fail 9 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10. Tank riser cap included in test? 3 Yes ❑ No ❑ NA [9 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 2 Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12. Starting level 13.50" 13.50" 13. Test start time 8: 19am 8: 19am 14. Ending level 13.50" 13.50" 15. Test end time 9: 10am 9: 1 gam 16. Test period 1 hour 1 hour 17. Level chane 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 Garrett Warren name : �� -UTO^- °C-�E,- , Tester's name : Date : 3- 12-2020 Tester's signature : i�o GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification