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SWRCB, January 2002 Page ( of 4
Secondary Containment Testing Report Form
Thisform is intendedfor use by contractors performing periodic testing of USTsecondary containment systems. Use the
appropriate pages ofthis form to report resultsfor all components tested. The completedform, written test procedures, and
printouts from tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: FASTBREAK MOBIL Date of Testing: 5 -15 -12
Facility Address: 4800 WHITE LN BAKERSFIELD CA
Facility Contact: Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector (ifpresent during testing): ERNIE MEDINA
2. TESTING CONTRACTOR INFORMATION
Company Name: Rich Environmental
Pass
Technician Conducting Test: RICH PHILLIPS
Not
Tested
Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester
License Type: C61/1)40 A HAZ
Fail
License Number: 809850
Manufacturer
EMMMUMMSEEM
Manufacturer Training
Component(s) Date Training Expires
INCON TS -STS 6/11/2012
X UDC 1 -2 X
3. SUMMARY OF TEST RESULTS
Component Pass Fail Not
Tested
Repairs
Made Component Pass Fail Not
Tested
Repairs
Made
UNL87 ANNULAR X UDC 1 -2 X
PLUS89 ANNULAR X UDC 3 X
PREM91 ANNULAR X UDC 4 -5 X
DIESEL ANNULAR X UDC 6 -7 X
UNL87 SEC. PIPE X UDC 8 X
PLUS89 SEC. PIPE X UDC 9 -10 X
PREM91 SEC. PIPE X UNL87 FILL SUMP X
DIESEL SEC. PIPE X PLUS89 FILL SUMP X
UNL87 STP X PREM91 FILL SUMP X
PLUS89 STP X DSL FILL SUMP X
PREM91 STP X UNL87 VPR BUCKET X
DIESEL STP X PLUS89 VPR BUCKET IX i 01 1
If hydrostatic testing was performed, describe what was done with the water after completion of tests:
RECYCLE AND REUSED
CERTIFICATION OF TECHNI WAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best ofmy knowledge, thefacts state this document are accurate and in full compliance with legal requirements
Technician's Signature: Date: ' -% 7—
YG ql(t-(
L / SWRCB, January 2002 Page of
Secondary Containment Testing Report Form
Thisform is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the
appropriate pages ofthisform to report resultsfor all components tested. The completedform, written test procedures, and
printoutsfrom tests (ifapplicable), should beprovided to thefacility owner /operatorfor submittal to the local regulatory agency.
I. FACILITY INFORMATION
Facility Name: FASTBREAK MOBIL I Date of Testing: 5 -15 -12
Facility Address: 4800 WHITE LN BAKERSFIELD CA
Facility Contact: Phone:
Date Local Agency Was Notified ofTesting:
Name of Local Agency Inspector (ifpresent during testing): ERNIE MENINA
2. TESTING CONTRACTOR INFORMATION
Company Name: Rich Environmental
Technician Conducting Test: RICH PHILLIPS
Credentials,, X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
License Type: C61 /D40 A HAZ License Number: 809850
Manufacturer
Manufacturer Trainine
Component(s) Date Training Expires
INCON TS -STS 6/11/2012
aa000
3. SUMMARY OF TEST RESULTS
If hydrostatic testing was performed, describe what was done with the water after completion of tests:
RECYCLE AND USED
CERTIFICATION OF TECHNIC RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the facts stated ' is document are accurate and in full compliance with legal requirements
Technician's Signature: Date:
Component
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If hydrostatic testing was performed, describe what was done with the water after completion of tests:
RECYCLE AND USED
CERTIFICATION OF TECHNIC RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the facts stated ' is document are accurate and in full compliance with legal requirements
Technician's Signature: Date:
SWRCB, January 2002
4. TANK ANNULAR TESTING
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Page -L of ¢
Test Method Developed By: Tank Manufacturer X Industry Standard Professional Engineer
Other (Spec)
Test Method Used: 0 Pressure X Vacuum Hydrostatic
Other (Spec)
Test Equipment Used: 4" DIAL GAUGE Equipment Resolution:
Is Tank Exempt From Testing ?'
Tank #
Rom
Tank #
lmiligiiiiiiummiiilm,
Tank #
11111
Tank #
0 Yes 0 No Yes No 0 Yes No Yes No
Tank Capacity:
Tank Material:
Tank Manufacturer:
Product Stored:
Wait time between applying
pressure/vacuum/water and
starting test
NOT TESTED
Test Start Time:
Initial Reading (Rj):
Test End Time:
Final Reading (RF):
Test Duration: 60 MIN 60 MM 60 MIN 60MIN
Change in Reading (RF -R):
Pass/Fail Threshold or Criteria:
Test Result: 0 Pass 0 Fail Pass Fail 0 Pass 0 Fail Pass 0 Fail
Was sensor removed for testing? Yes No NA 0 Yes 0 No NA Yes 0 No DNA 0 Yes 0No NA
Was sensor properly replaced and
verified functional after testing? Yes No 0 NA Yes No NA Yes No 0 NA Yes No 0 NA
COMMentS — (include information on repairs made prior to testing, and recommendedfollow -upfor, failed tests)
SINGLE WALL TANKS
Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary
containment, such as systems that are hydrostatically monitored or under constant vacuum, are exempt from periodic containment
testing. {California Code of Regulations, Title 23, Section 2637(a)(6))
SWRCB, January 2002
5_ SF,CC)NnARV PIPE TESTING
Page of a
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 4" DIAL GAUGE Equipment Resolution: .5%
Piping Run #
Piping Material:
Piping Run # Piping Run # Piping Run #
Piping Manufacturer.
Piping Diameter:
Length of Piping Run:
Product Stored:
Method and location of
piping-run isolation:
Wait time between applying
pressure/vacuum /water and
starting test:
NOT TESTED
Test Start Time:
Initial Reading (R4):
Test End Time:
Final Reading (RF):
Test Duration: 60 MIN 60 MIN 60 MIN 60 MIN
Change in Reading (R4-R,):
Pass/fail Threshold or
Criteria: 0 PSI 0 PSI 0 PSI 0 PSI
Test Result: Pass Fail Pass 0 Fail 0 Pass Fail Pass 0 Fail
COmmaits — rinclude information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
SINGLE WALL LINES
SWRCB, January 2002
6_ PIPING SUMP TESTING
Page of Q
Test Method Developed By: 0 Sump Manufacturer X Industry Standard 0 Professional Engineer
Other (Spec)
Test Method Used: Pressure Vacuum X Hydrostatic
Other (Specify)
Test Equipment Used: INCON TS -STS Equipment Resolution:
Sump #
Sump Diameter.
Sump # Sump # Sump #
Sump Depth:
Sump Material:
Height from Tank Top to Top of
Piping Penetration: Highest
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to testing:
Portion of Sump Tested'
Does turbine shut down when
sump sensor detects liquid (both
product and water) ?*
0 Yes 0 No NA Yes No NA Yes 0 No 0NA 0 Yes 0 No NA
Turbine shutdown response time
Is system programmed for fail -safe
shutdown ?' yes No NA Yes No DNA 0 Yes ONO NA 0 Yes No 0 NA
Was fail -safe verified to be
o rational ?*
0 Yes No NA Yes No NA Yes 0 No 0 NA Yes No 0 NA
Wait time between applying
pressure /vacuum /water and starting
test:
NOT TESTED
Test Start Time:
Initial Reading (R,):
Test End Time:
Final Reading (RF):
Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN
Change in Reading (RF -R,):
Pass/Fail Threshold or Criteria:
Test Result: Pass Fail 0 Pass 0 Fail 0 Pass 0 Fail Pass Fail
Was sensor removed for testing? Yes No 0 NA Yes C No DNA 0 Yes No NA 0 Yes D No NA
Was sensor properly replaced and
verified functional after testin . Yes No NA
D
Dyes D No NA Yes D No NA Yes No NA
Comments — (include information on repairs madeprior to testing, and recommendedfollow -upforfailed tests)
VO SIT SUMPS
Ifthe entire depth ofthe sump is not tested, specify how much was tested. If the answer to any ofthe questions indicated with an
asterisk (") is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160)
SWRCB, January 2002
7. UNDER- DISPENSER CONTAINMENT (UDC) TESTING
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Page of i.
Test Method Developed By: UDC Manufacturer X Industry Standard 0 Professional Engineer
Other (Spec)
Test Method Used: Pressure Vacuum X Hydrostatic
Other (Spec)
Test Equipment Used: INCON TS -STS I Equipment Resolution:
UDC # 1 -2rUDCrManufa:cturer: UNKNOWN
UDC # 3 UDC # 4-S UDC # 6 -7
UNKNOWN UNKNOWN UNKNOWN
FIBERGLASS FIBERGLASS FIBERGLASS FIBERGLASS
31" 31" 31" 31"
Height from UDC Bottom to Top
of Highest Piping Penetration:
9" 10" 9" 9"
Height from UDC Bottom to
Lowest Electrical Penetration:
3" 3" 3" 3"
Condition of UDC prior to
testing:
GOOD GOOD GOOD GOOD
Portion ofUDC Tested 11" 12" l 1" 11"
Does turbine shut down when
UDC sensor detects liquid (both
product and water),)
Yes No X NA Yes No X NA Yes No X NA 0 Yes No X NA
Turbine shutdown re22nse time
Is system programmed for fail-
safe shutdown? Yes No X NA Yes 0 No XNA 0 Yes 0 No X NA 0 Yes 0 No XNA
Was fail -safe verified to be
operational?*
Yes No X NA Yes No XNA Yes No XNA Yes No XNA
Wait time between applying
pressure/vacuum/water and
starting test
30MIN 30MIN 30MIN 30MIN
Test Start Time: 11:19 11:36 10:17 10:56 10:17 10:56 10:17 10:56
Initial Reading (Ri ): 3.355 3.355 5.290 5.283 2.554 2.500 2.585 2.593
Test End Time: 11:34 11:51 10:33 11:11 10:33 11:11 10:33 11:11
Final Reading (RF): 3.355 3.355 5.288 5.212 2.555 2.581 2.587 2.595
Test Duration: 15MIN 15MIN 15MIN I 15MIN 15MIN 15MIN 15MtN I 15MIN
Chan a in Readin (RF-R{ ): 000 000 002 1 -.001 001 001 002 +.002
Pass/Fail Threshold or Criteria: 002 002 002 002 002 002 002 -.002
Test Result: X Pass Fail X Pass Fail X Pass Fail X Pass Fail
Was sensor removed for testing? X Yes 0 No NA X Yes 0 No DNA X Yes No NA X Yes No NA
Was sensor properly replaced and
verified functional after testing? X Yes 0 No NA X Yes No 0 NA X Yes No NA X Yes No NA
C0MMeUtS - (include information on repairs madeprior to testing, andrecommendedfollow -upforfailed tests)
1 Ifthe entire depth ofthe UDC is not tested, specify how much was tested. If the answer to any ofthe questions indicated with an
asterisk ( *) is "NO" or "NA ", the entire UDC must be tested. (See SWRCB LG -160)
SWRCB, January 2002
7_ i1NDF.R- DiCPF.NSFR CONTAINMENT (UDCI TESTING
LIZ
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Test Method Developed By: UDC Manufacturer X Industry Standard 0 Professional Engineer
0 Other (Specify)
Test Method Used: 0 Pressure Vacuum X Hydrostatic
0 Other (Spec)
Test Equipment Used: INCON TS -STS Equipment Resolution:
UDC # 8 UDC # 9-10 UDC # UDC #
UDC Manufacturer. UNKNOWN UNKNOWN
UDC Material: FIBERGLASS FIBERGLASS
UDC Depth: 31" 31"
Height from UDC Bottom to Top
ofHighest Piping Penetration:
10" 9"
Height from UDC Bottom to
Lowest Electrical Penetration:
2" 3"
Condition ofUDC prior to
testing;
GOOD GOOD
Portion of UDC Tested 12" 12"
Does turbine shut down when
UDC sensor detects liquid (both
product and water)?*
0 Yes No X NA 0 Yes No XNA Yes No NA 0 Yes 0 No 0 NA
Turbine shutdown response time
Is system programmed for fail-
safe shutdown ?' 0 Yes 0 No X NA Yes 0 No X NA 0 Yes 0 No 0 NA 0Yes 0 No NA
Was fail -safe verified to be
operational?* yes 0 No X NA Yes No X NA 0 Yes 0 No NA 0 Yes 0 No 0 NA
Wait time between applying
pressure/vacuum/water and
starting test
30MIN 30MIN 30MIN 30MIN
Test Start Time: 11:38 11:52 11:38 11:52
Initial Reading 3.906 3.907 3.906 3.907
Test End Time: 11:51 12:07 11:51 12:07
Final Reading (RF): 3.906 3.906 3.906 3.906
Test Duration: 15MIN 15MIN 15MIN 15MIN 15MiN 15M1N 15MIN 15MIN
Change in Reading (RF-R,): 000 001 000 001
Pass/Fail Threshold or Criteria: 002 002 002 002
Test Result: X Pass 0 Fail X Pass Fail 0 Pass 0 Fail 0 Pass Fail
Was sensor removed for testing? X Yes 0 No NA X Yes 0 No DNA 0 Yes 0 No 0 NA C Yes 0No 0 NA
Was sensor properly replaced and
verified functional after testing? X Yes 0 No NA X Yes No NA Yes 0 No 0NA 0 Yes No 0NA
Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
Ifthe entire depth of the UDC is not tested, specify how much was tested. Ifthe answer to gnny of the questions indicated with an
asterisk ( *) is "NO" or "NA ", the entire UDC must be tested. (See SWRCB LG -160)
S WRCB, January 2002
8. FILL RISER CONTAINMENT SUMP TESTING
1
Page - of
Facility is Not Equipped With Fill Riser Containment Sums
Fill Riser Containment Sumps are Present, but were Not Tested
Test Method Developed By: Sump Manufacturer X Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum X Hydrostatic
Other (Spec)
Test Equipment Used: INCON TS -STS
Fill Sump # Fill Sump #
Sum Diameter:
Equipment Resolution:
Fill Sump Fill Sump#
Sum De the
Height from Tank Top to Top of
Highest Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to
testing:
Portion of Sump Tested
Sump Material:
Wait time between applying
pressure /vacuum/water and
starting test:
NOT TESTED
Test Start Time:
Initial Reading (R,):
Test End Time:
Final Reading (RF ):
Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN
Change in Reading (RF -R,):
Pass /Fail Threshold or Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
Is there a sensor in the sump? Yes No Yes No Yes No Yes No
Does the sensor alarm when
either product or water is
detected?
Yes No NA Yes No NA Yes No NA Yes No NA
Was sensor removed for testing? Yes No NA Yes No NA Yes No NA Yes No NA
Was sensor properly replaced and
verified functional after testin ? Yes No NA Yes No NA Yes No NA Yes No NA
Comments — (include information on repairs made prior to testing, and recommendedfollow -upfor failed tests)
NO FILL SUMPS
SWRCB, January 2002
9. SPILL/OVERFILL CONTAINMENT BOXES
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Page T of Q f
Facility is NoiEquipped With Spill/Overfill Containment Boxes
Spill/Overfill Containment Boxes are Present, but were Not Tested
Test Method Developed By: 0 Spill Bucket Manufacturer
Other (Spec)
X Industry Standard Professional Engineer
Test Method Used: Pressure
Other (Specify)
Vacuum X Hydrostatic
Test Equipment Used: INCON TS-STS Equipment Resolution:
Bucket Diameter:
mom 1111INNINIUM
Spill Box # 87VPR
12"
N me
Spill Box # 89VPR Spill Box # 91 VPR Spill Box #
12" 12"
Bucket Depth: 16" 16" 16"
Wait time between applying
pressure/vacuum/water and
starting test:
30MIN 30MIN 30MIN 30MIN
Test Start Time: 9:11 9:31 9:11 9:31 9:11 9:31
Initial Reading N): 4.469 4.489 1.894 1.892 2.754 2.752
Test End Time: 9:27 9:46 927 9:46 9:27 9:46
Final Reading (RF): 4.469 4.469 1.892 1.892 2.753 2.752
Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN
Change in Reading (RF -R,): 000 -.000 002 000 001 000
Pass/Fail Threshold or
Criteria: 002 -.002 002 002 002 002
Test Result: X Pass 0 Fail X Pass 0 Fail X Pass 0 Fail 0 Pass 0 Fail
Comments — (include information on repairs madeprior to testing, and recommendedfollow -upforfailed tests)
PHILE -TITE BUCKETS
rASTBREAK MOBIL
4806 WHITE LN
BAKERSFIELD CA
05/15012 9:27 AM
SUMP LEAK TEST REPORT
87UPR
TEST STARTED 9:11 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 4.4694 IN
END TIME 9:27 AM
END DATE 05/15/2012
END LEVEL 4.4692 IN
LEAK THRES)iOLD 0.002 IN
TEST RESULT PASSED
89VPR
TEST STARTED 9:11 AM
TEST STARTED 05 /15/2012
BEGIN LEVEL 1.6944 IN
END TIME 9:27 AM
END DATE 05/15/2012
EHD LEVEL 1.8929 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
91VPR
TEST STARTED 9:11 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 2.7543 IN
END TIME 9:27 AM
END DATE 05/15/2012
END LEVEL 2.7530 IN
LEW THRESHOLD 0.002 IN
TEST RESULT PASSED
ASTBREAK MOBIL
4800 WHITE LN
BAKERSFIELD CA
05/15/2012 9:46 AM
SUMP LEAK TEST REPORT
87UPR
TEST STARTED 9:31 AM
TEST STARTED K/15/2012INBEGINLEVEL9:46 AMENDTIME
END DATE 05/15/2012
END LEVEL 4.4690 IN
LEAK THRESHOLD 0.062 IN
TEST RESULT PASSED
89VPR
TEST STARTED 9:31 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 1.89ENDTIME
END DATE 01/>2501
END LEVEL IN
LEAK THRESHOLD O.e82 IDTESTRESULT
91VPR
TEST STARTED 9:31 AM
TEST STARTED 05 /15/2012
BEGIN LEVEL 2.7528 IN
END TIME 9:46 AM
END DATE 05./15/2012
523 NENDLEVELccaKTHRESHOLD0.002 _IN
UDC3
TEST STARTED 10:17 AP1
TEST STARTED 05/15/2012
BEGIN LEVEL 5.2905 IN
END TIME 10:33 AM
END DATE 05/15/2012
END LEUEL 5.2887 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
UDC4 -5
TEST STARTED 10:17 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 2.5534 IN
END TIME 10.33 AM
END DATE 05/15/2012
END LEVEL 2.5550 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
JDC6 -7
TEST STARTED- 10:17 AM
TEST STARTED 05 /15/2012
BEGIN LEVEL 2.5&.51 IN
END TIME 10:33 AM
END DATE 05/15/2012
END LEVEL 2.5870 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
UDC3
TEST STARTED 10 :56 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 5.2339 IN
END TIME 11:11 AM
END DATE 05/15/2012
END LEVEL 5.2825 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
UDC4 -5
TEST STARTED 10:56 All
TEST STARTED 05//5/2012
BEGIN LEVEL 2.5608 IN
END TIME 11:11 AM
END DATE 05/15/2012
END LEVEL 2.5618 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
UDC6 -7
TEST STARTED 10:56 Atli
TEST STARTED 05/15/2012
BEGIN LEVEL 2.5931 IN
END TIME 11:11 AM
END DATE . 05/15/2012
END LEVEL 2.5958 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT
C-ASTBREAK MOBIL 7 I'7•
4500 WHITE LN
BAKERSFIELD CA
05/15/2012 11:24 AM
SUMP LEAK TEST REPORT
UDC1 -2
TEST STARTED 11:19 AM
TEST STARTED 05 /15/2012
BEGIN LEVEL 3. 554 AMENDTIME
END DATE 05 /15/2012
END LEVEL 3.3556 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
rASTBREAK MOBIL
480x_+ WHITE. LN
BWE SFIEL4 CA
05/15/2012 11:51 AM
SUMP LEAK TEST REPORT
UDC, 1-2
MST STARTED 11:36 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 3.3556 IN
END TIME 11:51 AM
END DATE 05/15/2012
END LEVEL 3.3556 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT
PASSED
UDC8
TEST STARTED
TEST STARTED
BEGIN LEVEL
END TIME
END DATE
END LEUEL
LEAK THRESH01
TEST RESULT
11:36 AM
05/15/2012
1.7676 IN
11:51 AM
05/15/2012
1.7678 IN
D 0.002 IN
PASSED
UDC9 -10
TEST STARTED 11:36 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 3.9066 INENDTIME11:51 AM
END DATE 05/15/2012
END LEVEL 3.9067 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
UDC8
TEST STARTED 11:52 AN
TEST STARTED 05/15/2012
BEGIN LEVEL 1.7677 IN
END TIME 12:07 PM
END DATE 05/15/2012
END LEVEL 1.7679 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
UDC9 -10
TEST STARTED 11:52 AM
TEST STARTED 05/15/2012
BEGIN LEVEL 3.5079 IN
END TIME 12:07 Pt1
END DATE 65/15/2012
END LEVEL 3.9067 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
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