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S UST Spill Bucket CGR SOL. UTIOIVS 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 T1 : 87 T2 Diesel 2. Product stored Gas Diesel 3. Spill bucket capacity 5 Gallons 5 Gallons 4. Manufacturer OPW OPW ❑ Single-walled N 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 [9 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 X Product ❑ Product ❑ Product ❑ Product ❑ Product 7 . Spill bucket type ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor ❑ Vapor 8 . Liquid and debris removed from spill bucket:* N 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,)? 9 Pass ❑ Fail 91 Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail ❑ Pass ❑ Fail 10 . Tank riser cap included in test? I] 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? ❑ Yes ❑ No ❑ NA Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA ❑ Yes ❑ No ❑ NA 12 . Starting level 13.75" 135/8" 13 . Test start time 9: 15 am 9: 15 am 14. Ending level 13.75" 13 5/8" 15. Test end time 10: 15 am 10: 15 am 16. Test period 1 hour 1 hour 17. Level chan e 0 0 Test results : p Pass ❑ Fail N 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 ' ACGRS Garrett Warren name : Z49 7 °`° ° "' Tester' s name : Date : 01 /03/2019 Tester's signature . GPH = Gallons per hour, Y = Yes, N = No, NA = Not applicable, VPH = Vacuum/Pressure/Hydrostatic, [D = Identification