DERR-2025-000144

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LEAK RATE OF PRESSURE/VACUUM RELIEF VENT VALVES
TEST RESULT FORM
(40 CFR Part 63, Subpart CCCCCC)
Initial Other
Source Name:Source ID:
Source Address:
(address) (city) (zip)
Date of Test: Time of Test:
Valve 1:Grade (Check One)87 89 91 Other Manifolded
P/V Valve Manufacturer: Model Number:
Measured 2.00 inch Leak Rate (CFH):
Positive Cracking Pressure (“w.c.):
Measured 4.00 inch Leak Rate (CFH):
Negative Cracking Pressure (“w.c.):
Pass Fail
Pass Fail
Pass Fail
Pass Fail
Valve 2:Grade (Check One)87 89 91 Other Manifolded
P/V Valve Manufacturer: Model Number:
Measured 2.00 inch Leak Rate (CFH):
Positive Cracking Pressure (“w.c.):
Measured 4.00 inch Leak Rate (CFH):
Negative Cracking Pressure (“w.c.):
Pass Fail
Pass Fail
Pass Fail
Pass Fail
Valve 3:Grade (Check One)87 89 91 Other Manifolded
P/V Valve Manufacturer: Model Number:
Measured 2.00 inch Leak Rate (CFH):
Positive Cracking Pressure (“w.c.):
Measured 4.00 inch Leak Rate (CFH):
Negative Cracking Pressure (“w.c.):
Pass Fail
Pass Fail
Pass Fail
Pass Fail
Common conversion factors: 0.17 CFH = 80ml/min, 0.21 CFH = 100ml/min, 0.42 CFH= 200ml/min, 0.25=120ml/min
Comments:
BLOOMINGTON MARKET 6000342
141 W BRIGHAM RD ST GEORGE 84790
12/12/24 3 PM
OPW 623V
.016
3.62
-.0094
-6.16
OPW 623V
.022
4.11
-.0059
-5.87
Facility Name: Owner:
Address: Address:
City, State, Zip Code: City, State, Zip Code:
Facility I.D. #: Phone #:
Testing Company: Phone #: Date:
This procedure is to test the leak integrity of single- and double-walled spill buckets. See 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.
Tank Number
Product Stored
Spill Bucket
Capacity
Manufacturer
Construction Single-walled
Double-walled
Single-walled
Double-walled
Single-walled
Double-walled
Single-walled
Double-walled
Single-walled
Double-walled
Single-walled
Double-walled
Test Type Hydrostatic
Vacuum
Single-walled
Double-walled
Hydrostatic
Vacuum
Single-walled
Double-walled
Hydrostatic
Vacuum
Single-walled
Double-walled
Hydrostatic
Vacuum
Single-walled
Double-walled
Hydrostatic
Vacuum
Single-walled
Double-walled
Hydrostatic
Vacuum
Single-walled
Double-walled
Spill Bucket Type Product
Vapor
Product
Vapor
Product
Vapor
Product
Vapor
Product
Vapor
Product
Vapor
Liquid and debris
removed from
spill bucket?*
Yes No Yes No Yes No Yes No Yes No Yes No
Visual Inspection
(No cracks, loose
parts or separa-
tion of the bucket
from the fill pipe.)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Tank riser cap
included in test?
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Drain valve
included in test?
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Yes No
NA
Starting Level
Test Start Time
Ending Level
Test End Time
Test Period
Level Change
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.
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
*All liquids and debris must be disposed of properly.
Tester’s Name (print) ___________________________________ Tester’s Signature _________________________________
Tester’s Name (print) ___________________________________ Tester’s Signature __________________________________
Facility Name: Owner:
Address: Address:
City, State, Zip Code: City, State, Zip Code:
Facility I.D. #: Phone #:
Testing Company: Phone #: Date:
This data sheet is for inspecting automatic shutoff devices and ball float valves. See PEI/RP1200 Section 7 for inspection procedures.
Product Grade
Tank Number
Tank Volume, gallons
Tank Diameter, inches
Overfill Prevention Device Brand
Type Automatic
Shutoff Device
Ball Float
Valve
Automatic
Shutoff Device
Ball Float
Valve
Automatic
Shutoff Device
Ball Float
Valve
Automatic
Shutoff Device
Ball Float
Valve
Automatic
Shutoff Device
Ball Float
Valve
Automatic
Shutoff Device
Ball Float
Valve
1. Drop tube removed from tank? Yes No Yes No Yes No Yes No Yes No Yes No
2. Drop tube and float mecha-
nisms free of debris? Yes No Yes No Yes No Yes No Yes No Yes No
3. Float moves freely without
binding and poppet moves into
flow path?
Yes No Yes No Yes No Yes No Yes No Yes No
4. Bypass valve in the drop tube
open and free of blockage (if
present)?
Yes No
Not Present
Yes No
Not Present
Yes No
Not Present
Yes No
Not Present
Yes No
Not Present
Yes No
Not Present
5. Flapper adjusted to shut off
flow at 95% capacity?* Yes No Yes No Yes No Yes No Yes No Yes No
A “No” to any item in Lines 1-5 indicates a test failure.
1. Tank top fittings vapor- tight
and leak-free? Yes No Yes No Yes No Yes No Yes No Yes No
2. Ball float cage free of debris? Yes No Yes No Yes No Yes No Yes No
3. Ball free of holes and cracks
and moves freely in cage? Yes No Yes No Yes No Yes No Yes No Yes No
4. Vent hole in pipe open and
near top of tank? Yes No Yes No Yes No Yes No Yes No Yes No
5. Ball float pipe proper
length to restrict flow at 90%
capacity?***
Yes No Yes No Yes No Yes No Yes No Yes No
A “No” to any item in Lines 1-5 indicates a test failure.
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
* Use manufacturer’s suggested procedure for determining if automatic shutoff device will shut off flow at 95% capacity.
** If a ball float is found to fail the inspection, another method of overfill must be used.
*** Use manufacturer’s suggested procedure for determining if flow restriction device will restrict flow at 90% capacity.
Facility Name: Owner:
Address: Address:
City, State, Zip Code: City, State, Zip Code:
Facility I.D. #: Phone #:
Testing Company: Phone #: Date:
This procedure is to test the leak integrity of containment sumps. See PEI/RP1200 Section 6.5 for the test method.
Containment Sump ID
Containment Sump
Material
Liquid and debris
removed from sump?* Yes No Yes No Yes No Yes No Yes No Yes No
Visual Inspection (No
cracks, loose parts
or separation of the
containment sump.)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Containment Sump
Depth
Height From Bottom to
Top of Highest
Penetration
Starting Water Level
Test Start Time
Ending Water Level
Test End Time
Test Period (Minimum
test time: 1 hour)
Water Level Change
Pass/fail criteria: Must pass visual inspection. Water level drop of less than 1/8 inch.
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
*All liquids and debris must be disposed of properly.
Tester’s Name (print) ___________________________________ Tester’s Signature _________________________________
Facility Name: Owner:
Address: Address:
City, State, Zip Code: City, State, Zip Code:
Facility I.D. #: Phone #:
Testing Company: Phone #: Date:
This procedure is to test the leak integrity of containment sumps. See PEI/RP1200 Section 6.5 for the test method.
Containment Sump ID
Containment Sump
Material
Liquid and debris
removed from sump?* Yes No Yes No Yes No Yes No Yes No Yes No
Visual Inspection (No
cracks, loose parts
or separation of the
containment sump.)
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Containment Sump
Depth
Height From Bottom to
Top of Highest
Penetration
Starting Water Level
Test Start Time
Ending Water Level
Test End Time
Test Period (Minimum
test time: 1 hour)
Water Level Change
Pass/fail criteria: Must pass visual inspection. Water level drop of less than 1/8 inch.
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
*All liquids and debris must be disposed of properly.
Tester’s Name (print) ___________________________________ Tester’s Signature _________________________________