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f _� - •• S , �,� X01 UST Split Bucket SOLUTIONS EDELIVERE •� I ntegrity Testing Form �U�1hl 61round 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 T-1 91 2 . Product stored 91 supreme 3 . Spill bucket ca acit 5 gallons 4. Manufacturer OPW ❑ 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 ® 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 ® Product ❑ Product ❑ Product ❑ Product ❑ Product ❑ Product 7. Spill bucket type ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor 8 . Liquid and debris removed from spill bucket:* ❑ 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 pipes)? ® Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail [] Pass ❑ Fail ❑ Pass ❑ Fail 10. Tank riser cap included in test? ® 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? M Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12 . Starting level 9 : 15am 13 . Test start time 131/2" 14. Ending level 10 : 15am 15. Test end time 13 Wj 16 . Test period 1 hour 16 . Levelchan a 0 . 0" Test results : ® 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 118 inch; Vacuum single-walled only; Maintain at least 26 inches water column; Vacuum double-walled; maintain at least 12 inches water column. Comments : Repairs made to T-1 91 spill buckets , replaced failing OPW 2100 series with OPW Double Wall Edge. * All liquids and debris must be disposed of properly. Testing company name : CGRS , Inc . Tester's name : Leo Rangel Date : 03/05/19 Tester's signature :