HomeMy WebLinkAbout800 34TH STREET (3)SWII 2002 Page —1_ of
Secondary Containment Vesting Report Form
Thisform is intended for use by contractors performing periodic ladling ofUSrSecondary containment systems, Use the
appropriatepages ojlhisform to report resultsfor all components tested. The completedform, written testprocedures, and
printoutsfrom tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency,
1. FACILITY INFORMATION
Facility Name: Date of Testing:
Facility Address: _
Facility Contact: L phone:
Date Local Agency Was Notified of Testing:
Namc of Local Agency Inspector (ifpresent during testing):
2. TESTING CONTRACTOR INFORMATION
Company Name:
Technician Conducting Test
Credentials: P CSLB Licensed Contractor D SWRCB Licensed Tank Tcstcr
License Type: i License Number: yl
Maaufacturer Trainine
Manufacturer Component(s) Date Traittirt II
3. SUMMARY OF TEST RESULTS
r- ___ __.
If hydrostatic testing was performed, describe what was done with the water after completion of tests.,
CER'T'IFICATION OF TECHNICIAN R"PONSIBLF,' FOR CONDUCTING THIS TESTING
ro the best of my knowledge, the facts stated ' this document are accurate and in full compliance with legal requlrentents
Technician's Signature:
MW I mm=
Sao A moo
am
In
r- ___ __.
If hydrostatic testing was performed, describe what was done with the water after completion of tests.,
CER'T'IFICATION OF TECHNICIAN R"PONSIBLF,' FOR CONDUCTING THIS TESTING
ro the best of my knowledge, the facts stated ' this document are accurate and in full compliance with legal requlrentents
Technician's Signature:
SWRCB. January 2002
4, TANK ANNULAR TF.STTNf_
Page Z- of-
Test.Melbod Developed By: 0 Tank Mamtfaeturcr li fn—dustry Standard U Professional Engineer
0 Other (S,pec fy)
Test Method Used: C Pressure acuum n Hydrostatic
Other (Spec*)
Test Equipment Used:
Tank # Tank # '1
Equipment Resolution,
Tank t! Tank
Is Tank Exempt From Testing?' Ycs tKo 0 Yes a.iqro 0 Yes Wo Yes ONO
Tank Capacity;
Tank Material: F
Tank Manufacturer:
Product Stored:
Wait time between applying
pressure/vacuum/water and
startin test:
Vest Start Time: 4.
Initial Reading (RI):
Test End Timc:
Final Reading (Rp):
Test Duration;
Change in Reading (RF - )it):
Pass/FaiI Threshold or Criteria:
4 44
Test Result: M-11 -ass 0 Fail dYPass 0 Fall Fuss 0 Fail Pass Fail
Was scnsor removed for testing? os No NA No 0 NA R-Yes 0No 0 NA 0 Yes "0 No 0 NA
Was sensor properly replaced and
verified functional after testing?
es L7 No 0 NA
leS :)No NA f_cs 0 No NA l ]Yes 0 No NA
Comments — (include information on repairs made prior to testing, and recommendedfollow -upfor jailed tests)
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, arc exempt from periodic containment
testing. {California Code of Regulations, Title 23, Section 2637(a)(6))
SWRCB, January 2002
S. SECONDARY PIPE TESTING
Pagc ,_ of _ _L_
Test Method Developed Br R Piping Manufaeturcr, ndustry Standard 0 Professional Engineer
C Other (S eci )
Test Method Used: - ressurc 0 Vacuum 0 Hydrostatic
0 Other (spec)
Tcst Equipment Used: '
Piping ltun # i7j Piping Run #
Equipment Resolution: I.r
Piping Run # B Piping Run #
Piping Matefla1:
Piping Manuftiacturer:
Piping Diameter:
Length of Piping Run:
Vt
Product Stored:
Method and location of
i in -run isolation:
Wait timc betweOn applying
pressure /vaCUUm/water and
08ftin test:
Test Start Time: R
Initial Reading (Rt):
Test End Time: i
Final Rcading (RF):
Test Duration:
Change in Reading (RF -Rj):
Pass/Fail Threshold or
Criteria
Test Result; Ckfass C-1 -Fall ass 0 Fail mss 0 Fail 7 0 Pass 0 Fail
CornmentS •- (include;nformarion on re airsmadeprior to lesrixg, and recommendedfollow- !2forfalled rests)
SWRCB, January 2002
6. PIPING SUMP TES'T'ING
Page q of 7
Test Method Developed By; Cl Sump Manufacturer C4T659try Standard 0 Professional Engineer
Other (Specto)
Test Method Used: 0 Pressure 7 Vacuum VP ydrostatic
0 Other (Spec)
Test Equipment Used; rt —S Equipment Resolution:
Sump #L71 ffig Sump # f7 Sutnp # Sump #
Sump Diameter I /. 'o
Sump Depth- Ll I
Sump Material:
Height from Tank Top to Top of
High= Pi in Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to testing:
Portion ofSump Tcsted' p'
Doer: turbine shut down when
sump sensor detects liquid (both
product and water)?'
s No NA
e No 0 NA Yrcs 0No NA R Yes 0 No 0 NA
Turbine shutdown response time L
Is system programmed for fail ;cafe
shutdown?
ij es 0 No 0 NA ids ONO 0 NA Wi m No DNA n Yes 0 Nn 0 NA
Was fail-safe verified to be
operational?'
es No Cl NA LoYea rl No 0 NA ONO NA U Yes No NA
Wait time between apptying
pressure /vncuum/water and starting
test: 14 K
Test Start Time; 1
Initial Reading (1 ):
Test End Time;
Final Reading (RF): 10.9,7 i`
Test Duration:
Change in Reading (Pr?,,)-
Pass/Fail Threshold or Criteria: nn 2
Test Result: Pass ail Mass Fail B'1ass 0 Fail 0 Pass Fail
Was sensor removed for testing? No NA rVM No 0 NA T<9 No 0 NA Q Yes No NA
Was sensor properly replaced and
verified functional after testin ?
Ci[t"t'8 No 0 NA W ews 0No C] NA W!res 0 No 0 NA 0 Yes NO NA
COMMents -- (include information on repairs made prior to testing, andrecommendedfollow -up orfailed tests)
Ifthe entire depth of the sump is not testod, specify how much wav tested, If the answer to anX of the questions indicated with an
asterisk (*)is "NO" or "NA ", the entire sump must be tested. (Sae SWRCF3 LG -l60)
SWRCB, January 2002
7. UNDER - DISPENSER CONTAINMENT (UDC) TESTING
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Test Method Developed By: 0 UDC Manufacturer IRSdustry Standard 0 Professional Engineer
Other (Sped)
T'est Method Used; 0 Pressure 0 Vacuum W ydrwaatie
0 Other (Specify)
Test Equipment Used Equipment kcsolution 0. elnAn
UDC # I L UDC # tj UDC # UDC #
A-rumn 7-AAADUDCManufacturer:
UDC Material:
UDC Depth.,
Height from UDC Bottom to Top t
of Highest Pi2in& Penetration: to Frc
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition of UDC prior to
tcstin ;
Portion of UDC Tested
Does turbine shut down when
UDC sensor detects liquid (both 0 Yes 0-u Ll NA 11 Yes tM 0 NA C) Yes V0 0 NA n Yes ti'i'10 0NA
product and water)?*
Turbine shutdown m rise time v
Is system progtYtmmed for fail.
safe shutdown ?'
W-t`cs Q No DNA 9t -N —es 0 No NA DYes 0 No 0 NA neq 0No NA
Was fail -safe verified to be 03-t 5s No 0 NA elE_ 0 No LJ NA Yes n No 0 NA Wrees a No l7 NAoperational ?*
Wait time between applying
pressure / vacuum /water and
starting test rLI 14 E:
Test Start Time: Z L
Initial Reading ; 12_TX AA
Test End Time;
Final Reading 2 .jQ j . 7--Yy '
Test Duration;
Chan a in Reading (Rr-RI);
Pass/Fail 'Threshold or Criteria: d2 Opon z
Test Result: M -Pass 0 Fail Bgs 0 Fail 0 Pass ®-Nail amass 0 Fail
Was sensor removed for testing? Yes n No E3NA Q Yes fiNo 3 AKA a yes C No P<A 0 Ycs C1 No Lilt
Was sensor property replaced and Myc,$ 0 No NA r1 Yes C7 No lihiGt A No rt A Ayes 0No rf lgAverifiedfunctionalaftertesting?
Comments — (include information on repairs made rpfo/r to testing, and recommended ollow -upforfailed tests)
JN '-S 4 ,8 i e
1 If the entire depth of the UDC is not tested, specify how much was tested. If the wiswer to My of the questions indicated with an
asterisk ( *) is'NO" or "NA ", the entire UDC must be tested. (Soo SWRCB LG -I60)
SWRCB, January 2002
8. FILL RISER CONTAINMENT SUMP TESTING
Page _fib` of7-
Facility is NotEguipped With Fill Riser Containment Sum2s
Fill Riser Containment Sumps are Present, but were Not Tested
Test Method Developed By: D Sump Manufacturer 73 Industry Standard U Professional Engineer
Other (Speet J
Test Method Used: fJ Prassure D Vacuum 0 Hydrostatic
n Other (Specify)
Pest Equipment Used: EgWptnent Resolution:
Fill Sum 13 Fill Sump l! Fill Sump N Fill Sam #
SuMe Diameter:
Sump b th;
Kcight from Tank Top to Top of
Highest Piping Penetration:
Height from TatLk Top to f.owcst
Electrical Penetration;
Condition ofsump prior to
testing:
Portion of Sump Tested
sump Material:
Wait time between applying
pressureJvacuum /water and
starting test:
Test Start Time:
Initial Reading Rr ).'
Test End Time:
Final Reading . F :
Test Duzal',ion:
Chan a in Reading
Pass/Fail Threshold or Criteria:
test Result: pass 0 Fail D Pass 0 Fail 0 pass p Fail n Pass 0 Fall
Is there a sensor in the sump? U Yes D No Yes I7 No D Yes 0 No n Yes p No
Does the sensor alarm when D Ycs n No NAeitherproductorwateris Yes D No O NA 0 Yes No NA n Yes 0No NA
detected?
Was sensor removed for testing? Yes No 0 NA U Yes O No n NA D Yes No n NA U Yes 0 No NA
Was sensor properly replaced and a Yes 0 No 0 NA O Ycs No DNA 0 Ycs n No 0 Nn Yes n No 0NAverifiedfunotionaIaftertesting?
Comments — (include information on repairs made. prior to resring and recommended follow- upforfailed rests)
8WR63, 7armiary 2002 Page —7— of
Comments —(include information on repairs made prior to testing, and recommendedfollow -up orfuiled reds)
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