DERR-2024-005210

SPILL 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
PROVO CITY SHOPS 1000228
424 EAST 1325 SOUTH
PROVO, UTAH
STEVEN MARTIN AES TESTING
3-20-2024 801-540-9258
1 & 2 WEST
DSL/ R/UL
11 G
MORRISON
SWS
YES
PASS
NO
YES
4 3/8
12:03
4 3/8
13:14
1 HR 11 MIN
0
PASS
NO
1 & 2 EAST
DSL/ R/UL
11 G
MORRISON
SWS
YES
PASS
NO
YES
4 1/2
13:20
4 1/2
14:51
1 HR 31 MIN
0
PASS
NO
REUSED
SPILL CONTAINMENTS ARE ABOVEGROUND AND 100% VISABLE
Digitally signed by STEVEN B MARTIN
cn=STEVEN B MARTIN, o=AES, c=US
Date: 2024.03.20 13:53:11 -07'00'
Reason: I am the author of this document