HomeMy WebLinkAboutMinor Mod Re-test 8-11-17SWRCB, 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
Manufacturer Component(s) Date Training Expires
3. SUMMARY OF TEST RESULTS
Component Pass Fail
Not
Tested
Repairs
Made Component Pass Fail
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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12
Kern County Superintendent of School 08/11/2017
705 South Union Avenue Bakersfield, CA 93307
Aaron Straw (661) 979-8856
08/10/2017
Kris Karns
Kyle Self
✔
ICC CA UST Service Technician 10/28/2018
INCON TS-STS 11/08/2018
Fill Spill Bucket ✔
Vapor Spill Bucket ✔
08/11/2017
Water was hauled off by confidence UST services.
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 #
Bucket Diameter:
Bucket Depth:
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
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Please see incon results
22
✔
✔
TS-STS 0.00"
Fill Vapor
12.00"12.00"
14.00"14.00"
5min 5min
15 min 15 min
0.0625"0.0625"
✔✔