ADEM Form 20 "3 Year Spill Prevention Equipment (Spill Bucket) Integrity Test Report (Hydrostatic and Vacuum Method)" - Alabama

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Download this version of ADEM Form 20 for the current year.

What Is ADEM Form 20?

This is a legal form that was released by the Alabama Department of Environmental Management - a government authority operating within Alabama. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2018;
  • The latest edition provided by the Alabama Department of Environmental Management;
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  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of ADEM Form 20 by clicking the link below or browse more documents and templates provided by the Alabama Department of Environmental Management.

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Download ADEM Form 20 "3 Year Spill Prevention Equipment (Spill Bucket) Integrity Test Report (Hydrostatic and Vacuum Method)" - Alabama

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_____Fac #_____SPILLT_____Date_____
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) 270-5655
Facility Name:
Owner:
Address:
Address:
City, County, Zip:
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 performing the test to: Groundwater Branch, PO Box 301463 Montgomery, AL
36130-1463, or fax to: (334) 270-5631 or email to: USTcompliance@adem.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 Log which can be found on the ADEM website at
www.adem.alabama.gov/programs/water/groundwater.cnt.
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
 vacuum
 vacuum
 vacuum
 vacuum
 vacuum
 pressure
 pressure
 pressure
 pressure
 pressure
 hydrostatic
 hydrostatic
 hydrostatic
 hydrostatic
 hydrostatic
Test method used
 manufacturer’s
 manufacturer’s
 manufacturer’s
 manufacturer’s
 manufacturer’s
instructions
instructions
instructions
instructions
instructions
 yes
 yes
 yes
 yes
 yes
Basin free of cracks or holes?
 no
 no
 no
 no
 no
(if no, it fails without testing)
 yes
 yes
 yes
 yes
 yes
Water, fuel, trash & debris removed
 no
 no
 no
 no
 no
from basin prior to test?
 n/a
 n/a
 n/a
 n/a
 n/a
(dispose of properly)
 yes
 yes
 yes
 yes
 yes
Drain valve operational and seals
 no
 no
 no
 no
 no
properly?
 n/a
 n/a
 n/a
 n/a
 n/a
(where applicable)
Water, fuel, trash & debris removed
 yes
 yes
 yes
 yes
 yes
from basin prior to test?
 no
 no
 no
 no
 no
(dispose of properly)
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
Fill pipe cap seals properly?
 n/a
 n/a
 n/a
 n/a
 n/a
Was enough water added to
 yes
 yes
 yes
 yes
 yes
completely fill the basin?
 no
 no
 no
 no
 no
(Hydrostatic test only)
Test start time
_____:_____
_____:_____
_____:_____
_____:_____
_____:_____
Test end time
_____:_____
_____:_____
_____:_____
_____:_____
_____:_____
(hydrostatic test - minimum 1 hour)
Measured water level drop in inches
accurate to 1/16 inch
(Hydrostatic test)
Vacuum drop in inches water column
(vacuum test)
Results of test
(Hydrostatic test fails if level drops 1/8
pass
pass
pass
pass
pass
inch or more.) (Vacuum test fails if
fail
fail
fail
fail
fail
cannot maintain 30 inches water column
inconclusive
inconclusive
inconclusive
inconclusive
inconclusive
or if vacuum drops more than 4 inches
water column.)
Tester’s initials and date tested
/
/
/
/
/
/
/
/
/
/
Repairs Needed
Date of Repair
Description of any Repairs
ADEM Form 20 m1 7/15 m2 (revised 3/18)
_____Fac #_____SPILLT_____Date_____
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) 270-5655
Facility Name:
Owner:
Address:
Address:
City, County, Zip:
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 performing the test to: Groundwater Branch, PO Box 301463 Montgomery, AL
36130-1463, or fax to: (334) 270-5631 or email to: USTcompliance@adem.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 Log which can be found on the ADEM website at
www.adem.alabama.gov/programs/water/groundwater.cnt.
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
 vacuum
 vacuum
 vacuum
 vacuum
 vacuum
 pressure
 pressure
 pressure
 pressure
 pressure
 hydrostatic
 hydrostatic
 hydrostatic
 hydrostatic
 hydrostatic
Test method used
 manufacturer’s
 manufacturer’s
 manufacturer’s
 manufacturer’s
 manufacturer’s
instructions
instructions
instructions
instructions
instructions
 yes
 yes
 yes
 yes
 yes
Basin free of cracks or holes?
 no
 no
 no
 no
 no
(if no, it fails without testing)
 yes
 yes
 yes
 yes
 yes
Water, fuel, trash & debris removed
 no
 no
 no
 no
 no
from basin prior to test?
 n/a
 n/a
 n/a
 n/a
 n/a
(dispose of properly)
 yes
 yes
 yes
 yes
 yes
Drain valve operational and seals
 no
 no
 no
 no
 no
properly?
 n/a
 n/a
 n/a
 n/a
 n/a
(where applicable)
Water, fuel, trash & debris removed
 yes
 yes
 yes
 yes
 yes
from basin prior to test?
 no
 no
 no
 no
 no
(dispose of properly)
 yes
 yes
 yes
 yes
 yes
 no
 no
 no
 no
 no
Fill pipe cap seals properly?
 n/a
 n/a
 n/a
 n/a
 n/a
Was enough water added to
 yes
 yes
 yes
 yes
 yes
completely fill the basin?
 no
 no
 no
 no
 no
(Hydrostatic test only)
Test start time
_____:_____
_____:_____
_____:_____
_____:_____
_____:_____
Test end time
_____:_____
_____:_____
_____:_____
_____:_____
_____:_____
(hydrostatic test - minimum 1 hour)
Measured water level drop in inches
accurate to 1/16 inch
(Hydrostatic test)
Vacuum drop in inches water column
(vacuum test)
Results of test
(Hydrostatic test fails if level drops 1/8
pass
pass
pass
pass
pass
inch or more.) (Vacuum test fails if
fail
fail
fail
fail
fail
cannot maintain 30 inches water column
inconclusive
inconclusive
inconclusive
inconclusive
inconclusive
or if vacuum drops more than 4 inches
water column.)
Tester’s initials and date tested
/
/
/
/
/
/
/
/
/
/
Repairs Needed
Date of Repair
Description of any Repairs
ADEM Form 20 m1 7/15 m2 (revised 3/18)