HomeMy WebLinkAboutDERR-2024-010827SPILL PREVENTION TEST
Spill Bucket Hydrostatic Test Form
Facility Name Facility ID
Address Tester's Name
Test Date Phone
Tank Number
Product Stored
Capacity
Manufacturer
Construction
Liquid and Debris
Removed
Visual Inspection
No cracks, holes,
or separations
Tank Riser Cap
Included in Test
Is Drain Valve
Included in Test
Start Level
Start Time
Ending Level
End Time
Test Period
(minimum of 1 hour)
Change in Level
Test Results
Photos indicating water
Levels are Attached?
Pass / Fail Criteria: Must pass visual inspection, test duration at least one hour, must include photos with this
form, water level drop of less than 1/8 inch. Ref: PEI / RP 1200 6.2.5 Test Procedure
How was Liquid Disposed?
Comments
I certify under penalty of law that the above information is true, accurate and complete
Tester's Signature
HINES COUNTRY STORE 1200079
4275 NORTH 3800 WEST
PETERSON, UTAH 84054
STEVEN MARTIN AES TESTING UT 0121
8-26-2024 801-540-9258
3
PREMIUM
7 G
EBW
DW
PASS
NO
PREMIUM EBW SPILL BUCKET INTERSTICIAL TEST ONLY, O RING WAS REPLACED ON GUAGE AT
REINSTALLATION
Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2024.08.27 13:02:10 -07'00'
Reason: I am the author of this document