HomeMy WebLinkAbout SB989 RETEST RESULTS #721 4-29-16SWRCB, 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:_________________________
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11
#7721/Fastrip#22(North)04/29/2016
4013SouthHStreet,Bakersfield,CA93304
OmeroGarcia(661)393-7000
ShaneGardner
CameronMason
✔
ICC USTInstaller/Retrofitter 12/03/2016
INCON ST-STS 04/14/2018
UDC 9-10 ✔
UDC 11-12 ✔
UDC 13-14 ✔
UDC 15-16 ✔
Water was returned to test trailer.
04/29/2016
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
12
✔
✔
TS-STS 0.00"
9-10
A.P.P.
Clean
4.00"
12.00"
29.00"
Plastic
Environ
✔
N/A
✔
✔
✔
✔
✔
11-12
N/A
✔
✔
✔
✔
A.P.P.
Clean
4.00"
10.00"
29.00"
Plastic
Environ
✔
✔
13-1415-16
Environ Environ
Plastic Plastic
29.00"29.00"
10.00"10.75"
4.00"4.00"
Clean Clean
A.P.P.A.P.P.
✔✔
✔
✔
✔
✔
N/AN/A
✔✔
✔✔
✔✔