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Z"L 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 91 89 87 Diesel 2. Product stored Unleaded Unleaded Unleaded Diesel 3. Spill bucket capacity 5 Gallons 5 Gallons 5 Gallons 5 Gallons 4. Manufacturer OPW OPW OPW OPW ❑ Single-walled [1) Single-walled N Single-walled [E Single-walled ❑ Single -walled ❑ Single-walled 5. Construction [9 Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double walled ❑ Hydrostatic i] Hydrostatic ❑ Hydrostatic i] Hydrostatic ❑ Hydrostatic ❑ Hydrostatic ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Vacuum ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single -walled ❑ Single-walled ❑ Single-walled 6. Test type ❑ Double walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Product [N Product R Product I] Product ❑ Product ❑ Product 7. Spill bucket type ❑ Vapor ❑ Va or ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor 8 . Liquid and debris removed from spill bucket:* [!] Yes ❑ No 0 Yes ❑ No O Yes ❑ No [9 Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No 9. Visual inspection (No cracks , loose parts or separation of the bucket from the fill i e.) ? ❑ Pass ❑ Fail 91 Pass ❑ Fail 11 Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10. Tank riser cap included in test? 0 Yes ❑ No ❑ NA [5 Yes ❑ No ❑ NA ff] Yes ❑ No ❑ NA 2 Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 11 . Is drain valve included in test? p Yes ❑ No ❑ NA 0 Yes ❑ No ❑ NA Q Yes ❑ No ❑ NA Q Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12. Starting level 13.75' 14.00" 13.00" 14.50" 13. Test start time 8:39 am 8:39 am 8:39 am 8:39 am 14. Ending level 13.75" 14.00" 12.00" 13.50" 15. Test end time 9:39 am 9:39 am 9:39 am 9:39 am 16. Test period 1 hour 1 hour 1 hour 1 hour 17. Level Chan e 0 0 0 0 Test results : p Pass ❑ Fail N Pass ❑ Fail ❑ Pass N Fail ❑ Pass N 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 ICGRS Garrett Warren name : �� °« Testers name : Date : M- 2019 Tester's signature : GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatic, ID = Identification