HomeMy WebLinkAboutSB989 2015SWRCB, 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: Date of Testing:
Facility Address:
Facility Contact: Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (if present during testing):
2.TESTING CONTRACTOR INFORMATION
Company Name:
Technician Conducting Test:
Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester
License Type: License Number:
Manufacturer Training
ManufacturerComponent(s)Date TrainingExpires
3.SUMMARY OF TEST RESULTS
ComponentPassFail Not
Tested
Repairs
Made ComponentPassFail Not
Tested
Repairs
Made
If hydrostatic testing was performed, describe what was done with the water after completion of tests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements
Technician’s Signature:________________________________________________ Date:_________________________
$POGJEFODF6454FSWJDFT
*OD
")B[
$%
Samco#2 08/21/2015
3300WhiteLane,Bakersfield,CA93309
SamJouda(661)333-0000
07/14/2015
Shane Gardener
CameronMason
✔
ICC ServiceTech 10/13/2016
Incon TS-STS 10/16/2016
87Annular ✔87FillSump
91Annular ✔
87Secondary ✔
91Secondary ✔
87STP ✔
91STP ✔
UDC1-2 ✔
UDC5-6 ✔
UDC7-8 ✔
UDC9-10 ✔
UDC11-12 ✔
UDC3-4 ✔
✔
91FillSump ✔
87 Vapor Spill Bucket ✔
91 Vapor Spill Bucket ✔
Water returned to test tank.
08/21/2015
SWRCB, January 2002 Page ____ of ____
4.TANK ANNULAR TESTING
Test Method Developed By: Tank Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
Tank # Tank # Tank # Tank #
Is Tank Exempt From Testing?1
Yes No Yes No Yes No Yes No
Tank Capacity:
Tank Material:
Tank Manufacturer:
ProductStored:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
TestDuration:
Change in Reading (RF-RI):
Pass/Fail Threshold or Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
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 testing? Yes No NA Yes No NA Yes No NA Yes No NA
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
1 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)}
✔
✔
CalibratedGauges 0.0625"
87
✔
12000
Steel
Unknown
87Unleaded
5min.
0.00" hg
1hour
-10.00" hg
11:00 am
-10.00" hg
10:00 am
0.00" hg
✔
✔
✔
91
✔
12000
Steel
Unknown
91Unleaded
5min.
10:00 am
-10.00" hg
11:00 am
-10.00" hg
1hour
0.00"
0.00" hg
✔
✔
✔
SWRCB, January 2002 Page ____ of ____
5.SECONDARY PIPE TESTING
Test Method Developed By: Piping Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
Piping Run # Piping Run # Piping Run # Piping Run #
PipingMaterial:
Piping Manufacturer:
PipingDiameter:
Length of Piping Run:
ProductStored:
Method and location of
piping-run isolation:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
TestDuration:
Change in Reading (RF-RI):
Pass/Fail Threshold or
Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
✔
✔
CalibratedGauges
87
Fiberglass
Smith
3.00"
150.00'
87Unleaded
BootinSTP
5min.
10:00 am
5.00 PSI
11:00 am
5.00 PSI
1hour
0.00" hg
0.00" hg
✔
91
Fiberglass
Smith
3.00"
150.00'
91Unleaded
BootinSTP
5min.
10:00 am
5.00 PSI
11:00 am
5.00 PSI
1hour
0.00" hg
0.00" hg
✔
SWRCB, January 2002 Page ____ of ____
6.PIPING SUMP TESTING
Test Method Developed By: Sump Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
Sump # Sump # Sump #Sump #
Sump Diameter:
Sump Depth:
Sump Material:
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 Tested1
Does turbine shut down when
sump sensor detects liquid (both
product and water)?* Yes No NA Yes No NA Yes No NA Yes No NA
Turbine shutdown response time
Is system programmed for fail-safe
shutdown?* Yes No NA Yes No NA Yes No NA Yes No NA
Was fail-safe verified to be
operational?* Yes No NA Yes No NA Yes No NA Yes No NA
Wait time between applying
pressure/vacuum/water and starting
test:
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF-RI):
Pass/Fail Threshold or Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
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 testing? Yes No NA Yes No NA Yes No NA Yes No NA
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
1 If the entire depth of the sump is not tested, specify how much was tested. If the answer to any of the questions indicated with an
asterisk (*) is “NO” or “NA”, the entire sump must be tested. (See SWRCB LG-160)
SEE INCON RESULTS
✔
✔
TS-STS
87
37.00"
59.00"
Fiberglass
13.00"
14.00"
Clean
A.P.P.
✔
N/A
✔
✔
5 Min.
✔
✔
✔
91
37.00"
59.00"
Fiberglass
13.00"
14.00"
Clean
A.P.P.
✔
N/A
✔
✔
5 Min.
✔
✔
✔
SWRCB, January 2002 Page ____ of ____
7.UNDER-DISPENSER CONTAINMENT (UDC) TESTING
Test Method Developed By: UDC Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
UDC # UDC # UDC # UDC #
UDC Manufacturer:
UDC Material:
UDC Depth:
Height from UDC Bottom to Top
of Highest Piping Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition of UDC prior to
testing:
Portion of UDC Tested1
Does turbine shut down when
UDC sensor detects liquid (both
product and water)?*
Yes No NA Yes No NA Yes No NA Yes No NA
Turbine shutdown response time
Is system programmed for fail-
safe shutdown?* Yes No NA Yes No NA Yes No NA Yes No NA
Was fail-safe verified to be
operational?* Yes No NA Yes No NA Yes No NA Yes No NA
Wait time between applying
pressure/vacuum/water and
starting test
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF-RI):
Pass/Fail Threshold or Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
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 testing? Yes No NA Yes No NA Yes No NA Yes No NA
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
1 If the entire depth of the UDC is not tested, specify how much was tested. If the answer to any of the questions indicated with an
asterisk (*) is “NO” or “NA”, the entire UDC must be tested. (See SWRCB LG-160)
SEE INCON RESULTS
✔
✔
InconTSSTS
1-2
A.P.P.
Clean
1.00"
7.00"
30.00"
Plastic
Unknown
N/A
5min.
✔
✔
✔
✔
✔
✔
3-4
N/A
✔
5min.
✔
✔
✔✔
A.P.P.
Clean
1.00"
7.00"
30.00"
Plastic
Unknown
✔
✔
5-67-8
Unknown Unknown
Plastic Plastic
30.00"30.00"
7.00"7.00"
1.00"1.00"
Clean Clean
A.P.P.A.P.P.
✔✔
✔✔
✔✔
N/AN/A
✔✔
✔✔
5min.5min.
✔✔
SWRCB, January 2002 Page ____ of ____
7.UNDER-DISPENSER CONTAINMENT (UDC) TESTING
Test Method Developed By: UDC Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
UDC # UDC # UDC # UDC #
UDC Manufacturer:
UDC Material:
UDC Depth:
Height from UDC Bottom to Top
of Highest Piping Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition of UDC prior to
testing:
Portion of UDC Tested1
Does turbine shut down when
UDC sensor detects liquid (both
product and water)?*
Yes No NA Yes No NA Yes No NA Yes No NA
Turbine shutdown response time
Is system programmed for fail-
safe shutdown?* Yes No NA Yes No NA Yes No NA Yes No NA
Was fail-safe verified to be
operational?* Yes No NA Yes No NA Yes No NA Yes No NA
Wait time between applying
pressure/vacuum/water and
starting test
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF-RI):
Pass/Fail Threshold or Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
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 testing? Yes No NA Yes No NA Yes No NA Yes No NA
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
1 If the entire depth of the UDC is not tested, specify how much was tested. If the answer to any of the questions indicated with an
asterisk (*) is “NO” or “NA”, the entire UDC must be tested. (See SWRCB LG-160)
SEE INCON RESULTS
✔
✔
InconTSSTS
9-10
Plastic
A.P.P.
Clean
1.00"
7.00"
30.00"
Plastic
Unknown
✔
N/A
✔
5min.
✔
✔
✔
✔
11-12
N/A
✔
✔
5min.
✔
A.P.P.
Clean
1.00"
7.00"
30.00"
Unknown
✔
✔
SWRCB, January 2002 Page ____ of ____
8.FILL RISER CONTAINMENT SUMP TESTING
Facility is Not Equipped With Fill Riser Containment Sumps
Fill Riser Containment Sumps are Present, but were Not Tested
Test Method Developed By: Sump Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
Fill Sump # Fill Sump # Fill Sump # Fill Sump #
Sump Diameter:
Sump Depth:
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:
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
TestDuration:
Change in Reading (RF-RI):
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 testing? Yes No NA Yes No NA Yes No NA Yes No NA
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
SEE INCON RESULTS
✔
✔
InconTS-STS
8791
36.00"36.00"
60.00"60.00"
36.00"36.50"
12.00"12.00"
Clean Clean
38.00"38.00"
Fiberglass Fiberglass
5min.5min.
✔✔
✔✔
✔
✔
✔
✔
✔✔
SWRCB, January 2002 Page ____ of ____
9.SPILL/OVERFILL CONTAINMENT BOXES
Facility is Not Equipped With Spill/Overfill Containment Boxes
Spill/Overfill Containment Boxes are Present, but were Not Tested
Test Method Developed By: Spill Bucket Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
Spill Box # Spill Box # Spill Box # Spill Box #
BucketDiameter:
BucketDepth:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
TestDuration:
Change in Reading (RF-RI):
Pass/Fail Threshold or
Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
✔
✔
InconTS-STS
87-V 91-V
12.00"12.00"
11.00"11.00"
5min.5min.
10:00 am 10:00am
10.00"10.00"
0.00"
11:00 am 11:00 am
10.00"10.00"
60 Min 60 Min
0.00"
0.00"0.00"
✔✔