HomeMy WebLinkAbout2012 RESULTSSWRCB, January 2002 Page of
Secondary Containment Testing Report Form
This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the
appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and
printouts from tests (if applicable), should be provided to the facility owner /operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Mesa Marin Chevron & Food Mart
Date of Testing: 07/16/12
Facility Address: 1 1 101 Highway 178 Bakersfield, C.A. 93306
Facility Contact: Moe
Phone: 661- 366 -4886
Date Local Agency Was Notified of Testing: 4/13/12
Name of Local Agency Inspector (ifpresent during testing): Ester
2. TESTING CONTRACTOR INFORMATION
Company Name: Confidence UST Services
Pass
Technician Conducting Test: Frank Landa
Not
Tested
Credentials: x CSLB Licensed Contractor
❑ SWRCB Licensed Tank Tester
License Type: CSLB
Fail
License Number:804904
Manufacturer
Manufacturer Training
Component(s) ) Date Training Expires
Franklin Fueling
Incon 9/20/12
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3. SUMMARY OF TEST RESULTS
Component
Pass
Fail
Not
Tested
Repairs
Made
Component
Pass
Fail
Not
Tested
Repairs
Made
U.D.C. 1 -2
X
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U.D.C. 3-4
X
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If hydrostatic testing was performed, describe what was done with the water after completion of tests:
Water was put back into testing trailer
CERTIFICATION OF TECHNICIAJ5LAESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the fa is stated t ti do ument are accurate and in full compliance with legal requirements
Technician's Signature Date: 07/16/12
SWRCB, January 2002
7. UNDER- DISPENSER CONTAINMENT DC TESTING
Page of
Test Method Developed By: ❑ UDC Manufacturer x Industry Standard ❑ Professional Engineer
❑ Other (Specify)
Test Method Used: ❑ Pressure ❑ Vacuum x Hydrostatic
❑ Other (Spec)
Test Equipment Used: Ts -sts
Equipment Resolution:
gg
UDC #1 -2
UDC #34
UDC #
UDC #
UDC Manufacturer:
Environ
Environ
UDC Material:
Com sit
Compsit
UDC Depth:
12"
12"
Height from UDC Bottom to Top
of Highest Piping Penetration:
0"
0"
Height from UDC Bottom to
Lowest Electrical Penetration:
0"
0"
Condition of UDC prior to
testing:
Clean & Dry
Clean & Dry
Portion of UDC Tested
8"
8"
Does turbine shut down when
UDC sensor detects liquid (both
product and water) ?*
❑ Yes ❑ No xNA
❑ Yes ❑ No xNA
❑ Yes ❑ No ❑ NA
❑ Yes ❑ No ❑ NA
Turbine shutdown response time
N.A.
N.A.
Is system programmed for fail-
safe shutdown ?*
❑ Yes ❑ No xNA
❑ Yes ❑ No xNA
❑ Yes ❑ No ❑ NA
❑ Yes ❑ No ❑ NA
Was fail -safe verified to be
operational?*
❑ Yes ❑ No xNA
❑ Yes ❑ No xNA
❑ Yes ❑ No ❑ NA
❑ Yes ❑ No ❑ NA
Wait time between applying
pressure /vacuum /water and
starting test
5 min
5 min
Test Start Time:
Initial Reading (RI):
bee 11
CON
Test End Time:
Ran
11ta
Final Reading (RF):
Test Duration:
Change in Reading (RF -R,):
Pass /Fail Threshold or Criteria:
Test Result:
X Pass ❑ Fail
X Pass ❑ Fail
❑ Pass ❑ Fail
❑ Pass ❑ Fail
Was sensor removed for testing?
❑Yes ❑ No X NA
❑Yes ❑ No X NA
❑ Yes ❑ No ❑ NA
❑ Yes ❑ No ❑ NA
Was sensor properly replaced and
verified functional after testing?
❑Yes ❑ No X NA
❑Yes ❑ No X NA
[]Yes ❑ No ❑ NA
❑ Yes ❑ No ❑ NA
Comments — (include information on repairs made prior to testing, and recommended follow -up for failed tests)
Replaced (9) piains- penetrations all tested ok
' If the entire depth of the UDC is not tested, specify how much was tested. If the answer to a� of the questions indicated with an
asterisk ( *) is "NO" or "NA ", the entire UDC must be tested. (See SWRCB LG -160)
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