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a 01 UST Spill Bucket SCDL.UTIDNSRS 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 Diesel 2. Product stored Gas Diesel 3. Spill bucket capacity 5 Gallons 5 Gallons 4. Manufacturer OPW OPW 9 Single-walled N Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled ❑ Single-walled 6. Construction ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled 0 Hydrostatic 0 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 type ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled ❑ Double-walled 19 Product Q Product ❑ Product ❑ Product ❑ Product ❑ Product 7. Spill bucket type ❑ Vapor ❑ Vapor ❑ vapor ❑ Vapor ❑ Vapor ❑ Vapor 8. Liquid and debris removed from spill bucket:* 0 Yes ❑ No 0 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.),? D Pass ❑ Fail l] Pass ❑ Fail [] Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10. Tank riser cap included in test? 9Yes ❑ No ❑ NA Fil Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA E] Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA El Yes ❑ No ❑ NA 11 . Is drain valve included in test? O Yes ❑ No ❑ NA [9 Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12. Starting level 13.75" 13 5/8" 13. Test start time 9: 15 am 9: 15 am 14. Ending level 13.75" 13 5/W 15. Test end time 10: 15 am 10:15 am 16. Test period 1 hour 1 hour 17. Level chane 0 0 Test results : p Pass ❑ Fail 0 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass [] Fail ❑ Pass [] Fall ❑ Pass ❑ Fail Pass/fail criteria: Must pass visual inspection. Hydrostatic: Waterlevel drop ofless 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 name : SOWTt °°"°""' Tester's name : Garrett Warren Date : 01 /03/2019 Tester's signature ._ i GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = VacuumfPressure/Hydrostatic, ID = Identification