HomeMy WebLinkAbout8624 CALIFORNIA AVENUE (2)SWRCB, January 2002 Page of
Secondary Containment Testing Report Form
This form is intendedfor use by contractors performingperiodic testing ofUST secondary containment systems. Use the
appropriate pages ofthisform to report resultsfor all components tested The completedform, written test procedures, and
printouts from tests (fapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: DEL TACO Date of Testing: 5/8/12
Facility Address: 8624 CALIFORNIA AVENUE, BAKERSFIELD
Facility Contact: Phone:
Date Local Agency Was Notified ofTesting:
Name of Local Agency Inspector (fpresent during testing):
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Pass
Technician Conducting Test: JAMES RICH
Not
Tested
Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester
License Type: C61 / D40
FailI
License Number: 809850
Manufacturer
Manufacturer
Training
Component(s) Date Training Expires
X 0
3. SUMMARY OF TEST RESULTS
Component Pass Fail Not
Tested
Repairs
Made Component Pass FailI Not
Tested
Repairs
Made
UNL87 — FROM STP TO DISP #7/8 & X 0 0
9/10 SECONDARY 0 0 0
PREM91 — FROM STP TO DISP #7/8 X 0 0
9/10 SECONDARY 0
0
0
1
1 0
If hydrostatic testing was performed, describe what was done with the water after completion oftests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best ofmy knowledge, thefacts stated in this document are accurate and in full compliance with legal requirements
Technician's Signature: Date: 5/8/12
SWRCB, January 2002
5. SFCONDARY PIPE TESTING
4b%v
Page —1/ of 2/
Test Method Developed By: Piping Manufacturer X Industry Standard Professional Engineer
Other (Spec)
Test Method Used: X Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
Piping Run # 87
Piping Material: PLASTIC
Piping Run #91 Piping Run # Piping Run #
PLASTIC
Piping Manufacturer: APT APT
Piping Diameter: 1.5" 1.5"
Length of Piping Run: 50' 50'
Product Stored: UNL87 PREM91
Method and location of
piping-run isolation:
TEST BOOT STP
SUMP
TEST BOOT STP
SUMP
Wait time between applying
pressure /vacuum/water and
starting test:
1 -HOUR 1 -HOUR
Test Start Time: 2:00 2:00
Initial Reading (RI): 5.2PSI 5.2PSI
Test End Time: 3:00 3:00
Final Reading (RF): 5.2PSI 5.2PS1
Test Duration: I -HOUR l -HOUR
Change in Reading (RF -Ri): 0 0
Pass/Fail Threshold or
Criteria: 0 0
Test Result: X Pass Fail X Pass Fail Pass Fail Pass Fail
COmments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
SB989 TESTING FAILURE REPORT
SITE NAME: DEL TACO DATE 518/12
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO' COMPLETE
TESTING.
REPAIRS:
HAD TO REPLACE PRODUCT LINE
LABOR: 87- REPLACED PRODUCT LINE FROM STP TO DISP #7/8
9/10
91- REPLACED PRODUCT LINE FROM DISP #7/8
TO #9/10
PARTS INSTALLED: 6- REPAIR PENETRATION, 6 TEST BOOTS & 6 BARB
FITTINGS
NAME: TITLE:
SIGNATURE:
THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY OF NOTIFYING
THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR
ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE.
A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR
CONVIENENCE.