HomeMy WebLinkAbout14134 003773 113 03-31-2021 ANWALK ALC ANNUAL WALKTHROUGH INSPECTION 61948.73 SPILLT
ADEM
3 YEAR SPILL PREVENTION EQUIPMENT (SPILL BUCKET)
INTEGRITY TEST REPORT (HYDROSTATIC AND VACUUM METHOD)
Questions on how to com late this form should be tlirected to the Groundwater drench,VST Cam e lionsSection a6 334 270-5655
Facilit Name: p Owner: Qt S n
Address: p w u Address: I 3A 54
Cit COUnI ,ZI : £nl,1C Ct, City.State, Z1
Facilit I.D.#: Phone#: r't
Tester Name: Tester Phone#: L (og-
Tester Company:
Inbfructrona
1. Submit a completed copy of this form within 30 days of performing the test to: Groundwater Branch,PO Box 301463 Montgomery,AL
36130-1463,or fax to: (334)270-5631 or email to: UST lI u) d I b o .
2. This form allows you to record up to 5 ADEM Unique Tank Numbers,assuming that me Facility ID Number and test method remain
the same.
3. Double walled spill prevention equipment does not require testing.
4. Single and double walled spill prevention equipment must also be checked every 30 days in accordance with the Walkthrough
Inspection requirements. See ADEM 30 day Walkthrough Inspection Checklist Log which can be Pound on the ADEM website at
www edam aI.bama / Not / d t t.
5. Testing must be performed in accordance with a nationally recognized code of practice(such as PEI RP-1200 or equivalent)or the
manufacturer's instructions.
6. Keep a record copy of this testing for 3 years.
Code of Practice or Manufacturer's Instructions used:
ADEM Unique Tank#
Product Stored
❑vacuft ❑vacuum ❑vacuum ❑vacuum ❑vacuum
❑It assure assure ❑pr�ssure pressure ❑pressure ❑pressure
Test method used f8'fiydrostatic LMydrostatic Whydrostatic ❑hydrostatic ❑hydrostatic
❑manufacturer's ❑manufacturer's ❑manufacturers ❑manufacturer's 0 manufacturer's
in coons in Lllons instructions instructions instructions
Basin free of cracks or holes? yes Wyss ❑yes ❑yes El yes
(e no,it fails without testing) ❑no 0 no ❑no ❑no ❑no
Water,fuel,trash&debris remove 0 yes yes ❑yes ❑yes 0 yes
from basin prior to test? ❑no ❑no ❑no 0 no 0 no
(dispose of properly) ❑his ❑n/a ❑n/a 0 n/a 0 n/a
Drain valve operational and seals ❑yes ❑yes 0 yes ❑yes ❑yes
propedy? ❑ny ❑ny ❑❑ no ❑no ❑no
(where applicable) ta'n/a fd'n/a n/a 0 n/a ❑hills
Water,tuel,trash&debris removed
from basin prior to test? �s 0 Yea ❑yes ❑yes [3yes
did a of ro erl El no ❑no ❑no ❑no ❑no
yes yes _0 yes
❑yes
Fill pipe cap seals property? Dyes
y? ❑no ❑no ❑no ❑no ❑no
Was enough water added to
completely fill the basin? yes �s ❑yes ❑yes ❑yes
H deastatic test art Cl 00 ❑no ❑no ❑no ❑no
Test start time
Test end time —
h drostasc lest-minimum Till
hour --
Measured waterlevel drop in inches
accurate to 1/16 inch r�
(Hydrostatic test) (�
Vacuum drop in inches water column
A
cuum testesults of test test fails if level drops 1/8 ✓ �/re.) (Vacuum test fails if Mll Ell 13pass opass opass
ain 30 inches water Column Ofall Ofail Ofail Ofail 0fai1
drops more than 4 inches Oinconclusive oinconclusive oinconclusive oinconclusive oinconclusive
ater column.itials and date tested / /' / / / / / /airs Needed Date of Re air Descri ion of an Repairs
ADEM Form 20 m1 7115 m2(revised 3118)