HomeMy WebLinkAbout12724 009491 101 12-14-2020 SPILLT SLA SPILL BASIN TEST RESULT 71981.66 SPILLT
ADEM
3 YEAR SPILL PREVENTION EQUIPMENT (SPILL BUCKET)
INTEGRITY TEST REPORT (HYDROSTATIC AND VACUUM METHOD)
Questions on how to complete this form should be directed to the Groundwater Branch,UST Compliance Section at 334 270-5855
Facility Name: Owner:
Address: Address:
City, County,Zi City, State,Zip:
Facility I.D.#: Phone#:
Tester Name: Tester Phone#:
Tester Company:
Instructions
1. Submit a completed copy of this form within 30 days of pedorming the test to: Groundwater Branch,PO Box 301463 Montgomery,AL
36130-1463,or fax to: (334)270-5631 or email to: USTcomolianceoadenn alabama.gov.
2. This form allows you to record up to 5 ADEM Unique Tank Numbers,assuming that the 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 Lag which can be found on the ADEM website at
w .adem.alabama.gov/programs/water/amundwater.cnt.
5. Testing must be performed in accordance with a nationally recognized code of practice(such as PEI RP-1200 or equivalent)or the
manufacturers instructions.
6. Keep a record copy of this testing for 3 years.
Code of Practice or Manufacturers Instructions used:
ADEM Unique Tank#
Product Stored
❑vacuum ❑vacuum ❑vacuum ❑vacuum ❑vacuum
❑pressure ❑ pressure ❑pressure ❑pressure ❑pressure
Test method used ❑hydrostatic ❑ hydrostatic ❑hydrostatic ❑hydrostatic ❑hydrostatic
❑manufacturer's ❑ manufacturers ❑manufacturer's ❑manufacturer's ❑manufacturer's
instructions instructions instructions instructions instructions
Basin free of cracks or holes? ❑yes ❑yes ❑yes ❑yes ❑yes
(it no,it fails without testing) ❑ no ❑no ❑ no ❑ no ❑ no
Water,fuel,trash&debris removed ❑yes ❑yes ❑yes ❑yes ❑yes
from basin prior to test? ❑no ❑ no ❑no ❑no ❑no
(dispose of properly) ❑ his ❑n/a ❑ his ❑ his ❑ me
Drain valve operational and seals ❑yes ❑yes ❑yes ❑yes ❑yes
properly? ❑no ❑ no ❑no ❑no ❑no
(where applicable) ❑his ❑ Na ❑ma ❑me ❑n/a
Water,fuel,trash&debris removed D yes ❑yes ❑yes ❑yes ❑yes
from basin prior to test? ❑ no ❑no ❑ no ❑ no ❑ no
(dispose of properly)
❑yes ❑yes ❑yes ❑yes ❑yes
Fill pipe cap seals properly? ❑no ❑ no ❑no ❑no ❑no
Was enough water added to ❑yes ❑yes ❑yes ❑yes ❑yes
completely fill the basin? ❑no ❑no ❑ no ❑ no ❑ no
H drostatictest only)
Test start time
Test end time
(hydrostatic test-minimum 1 hour
Measured water level drop in inches
accurate to 1/16 inch
(Hydrostatic lest)
Vacuum drop in inches water column
vacuum test
Results of test
(Hydrostatic test fails if level drops 118 Opass 13pas8 ❑pass 13pass Opass
inch or more.) (Vacuum test fails If
cannot maintain 30 inches water column Ofail Dfail Ofail Dfail Ofail
or if vacuum drops more than 4 inches Olnconcluslve Dlnconclusive Dlnconcluslve Dlnconcluslve Dlnconcluslve
water column.
Testers initials and date tested I / / / / / / I / / / /
Repairs Needed Date of Re it Description of any Repairs
ADEM Form 20 ml 7/15 m2(revised 3/18)