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SWRCB, January 2002 Page k of jji-
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Secondary Containment Testing Report Form
Thisform is intendedfor use by contractors performing periodic testing ofUST secondary containment systems. Use the
appropriate pages ofthis form to report resultsfor all components tested The completedform, written test procedures, and
printoutsfrom tests (fapplicable), should beprovided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACYIJTV TNFnRMATinN
Facility Name: A -1 FOOD STORE Date of Testing: 4/13/12
Facility Address: 1200 "H" STREET, BAKERSFIELD
Facility Contact: Phone:
Date Local Agency Was Notified of Testing:
Name ofLocal Agency Inspector (fpresent during testing):
2_ TF.ST1NV. CnNTRACTnR TNFnRMATinN
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test: JAMES J. RICH
Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
License Type: C61 / D40 License Number: 809850
Manufacturer
Manufacturer Training
Component(s) Date Training Expires
INCON INCON TS -STS 5 -27 -12
3. SUMMARY OF TEST RESULTS
Component Component
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Ifhydrostatic testing was performed, describe what was done with the water after completion oftests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
T6fife best ofmy knowledge, thefacts stated In this document are accurate and infull compliance with legal requirements
Technician's Signature: Date: 4/13/12
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SWRCB, January 2002
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Page 1 of 'L-
Test Method Developed By: Piping Manufacturer X Industry Standard Professional Engineer
Other (Spec)
Test Method Used: X Pressure 0 Vacuum Hydrostatic
Other (Spec)
Test Equipment Used: Equipment Resolution:
Piping Run # 87 Piping Run # Piping Run # Piping Run #
Piping Material: PLASTIC
Piping Manufacturer: APT
Piping Diameter. 1.5"
Length ofPiping Run: 30'
Product Stored: 87
Method and location of
piping -run isolation: TEST BOOT 87 -STP
Wait time between applying
pressure /vacuum/water and
starting test:
10MIN
Tpst :Start Time: 10:40
Initial Reading (R,): 5.0
Test End Time: 11:40
Final Reading (RF): 5.0
Test Duration: 1 HOUR
Change in Reading (RF -&): 0
Pass/Fail Threshold or
Criteria: 0
J,est;Result .: X Pass Fail Pass Fail Pass Fail Pass Fail
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Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)