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Home My WebLink About420 34TH STREET (4)y63 `.. SWRCB, January 2002 Page ,c- of Secondary Containment Testing Report Form Thisform 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 printoutsfrom tests (ifapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: MEMORIAL HOSPITAL Date ofTesting: 5/7/12 Facility Address: 42034.. STREET, BAKERSFIELD Facility Contact: Phone: Date Local Agency Was Notified of Testing; 3/28/12 Name ofLocal Agency Inspector (fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: RICH ENVIRONMENTAL Pass Technician Conducting Test: RICH PHILLIPS Not Tested Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester License Type: C61/D40 A HAZ License Number: 809850 Manufacturer Training Manufacturer Component(s) Date Training Expires INCON TS -STS 6/11/2012 X 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made GEN DSL ANNULAR X BOILER DSL ANNULAR 0 0 X 0 0 GEN DSL SUPPLY SEC PIPE 1 X 0 0 0 0 BOILER DSL SUPPLY SEC PIPE X 0 0 0 0 0 0 GEN DSL RETURN SEC PIPE X 0 0 0 0 0 0 BOILER DSL RETURN SEC PIPE X 0 0 0 0 0 GEN DSL STP X 0 0 BOILER DSL STP X GEN DSL FILL SUMP X D 0 0 BOILER DSL FILL SUMP X 0 0 1 1 0 0 0 0 0 I 1 0 0 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECH IAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best ofmy knowledge, the facts st to this document are accurate and infull compliance with legal requirements Technician's Signature: Date: 5/7112 SWRCB, January 2002 4. TANK ANNULAR TESTING 4 36Ir Page _;_z of Test Method Developed By: Tank Manufacturer X Industry Standard Professional Engineer 0 Other (Spec) Test Method Used: Pressure X Vacuum Hydrostatic Other (Specify) Test Equipment Used: 4" DIAL GAUGE Equipment Resolution: Is Tank Exempt From Testing ?' Tank # ;EN Tank #BOILER Tank # Tank # Yes No Yes No 0 Yes No 0 Yes No Tank Capacity : Tank Material: Tank Manufacturer: Product Stored: Wait time between applying pressure/vacuum/water and starting test: NOT TESTED Test Start Time: Initial Reading (Rr): Test End Time: Final Reading (RF): Test Duration: 60 MIN 60 MIN 60 MIN 60MIN Change in Reading (RrR,): Pass/Fail Threshold or Criteria: Test Result:.. 0 Pass Fail Pass 0 Fail 0 Pass 0 Fail 0 Pass Fail Was sensor removed for testing? Yes No NA 0 Yes 0 No NA Yes No 0 NA 0 Yes No NA Was sensor properly replaced and verified functional after testing'? Yes 0 No NA Yes 0No NA Yes No NA 0 Yes No 0 NA Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) WET ANNULARS 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)) SWRCB, January 2002 S. SECONDARY PIPE TESTING y(f 3 G Page 3 of Test Method Developed By: Piping Manufacturer X Industry Standard Professional Engineer Other (Specify) Test Method Used: X Pressure Vacuum Hydrostatic Other (Spec) Test Equipment Used: 4" DIAL GAUGE Equipment Resolution: .5% Piping Run #GEN SUPPLY Piping Material: FIBERGLASS Piping Run #BOILER SUPPLY Piping Run #GEN RETURN Piping Run #BOILER RETURN FIBERGLASS FIBERGLASS FIBERGLASS Piping Manufacturer: SMITH SMITH SMITH SMITH Piping Diameter: 3" 3" 3" 3" Length of Piping Run: 50' 100' 50' 100' Product Stored: DSL DSL DSL DSL Method and location of piping-run isolation• BOOT IN SUMP BOOT IN SUMP BOOT IN SUMP BOOT IN SUMP Wait time between applying pressure/vacuum/water and starting test: 30 MIN 30 MIN 30 MIN 30 MIN Test Start Time: 10:30 9:15 10:30 9:15 Initial Reading (R,): 5 6.5 5 6.5 Test End Time: 11:30 10:15 11:30 10:15 Final Reading (RF): 0 6.5 0 6.5 Test Duration: 60 MIN 60 MIN 60 MIN 60 MIN Change in Reading (RF -R,): 5 0 5 0 Pass/Fail Threshold or Criteria 0 PSI 0 PSI 0 PSI 0 PSI Test Result: Pass X Fail X Pass Fail Pass X Fail X Pass Fail Comments — (include information on repairs made prior to testing and recommendedfollow -upforfailed tests) EMERGENCY GENERATOR RETURN AND SUPPLY FAILED SWRCB, January 2002 6. PIPING SUMP TESTING y 3G,7 Page y of -7—f, Test Method Developed By: Sump Manufacturer X Industry Standard D Professional Engineer 0 Other (Specify) Test Method Used: 0 Pressure D Vacuum X Hydrostatic Other (Specify) Test Equipment Used: INCON TS -STS Equipment Resolution: Sump #GEN Sump #BOILER Sump # Sump # Sump Diameter: 42" 42" Sump Depth: 36" 36" Sump Material: FIBERGLASS FIBERGLASS Height from Tank Top to Top of Highest Piping Penetration: 6" 6" Height from Tank Top to Lowest Electrical Penetration: 12" 12" Condition ofsump prior to testing: GOOD GOOD Portion ofSump Tested' 8" 8" Does turbine shut down when sump sensor detects liquid (both product and water)?* Yes D No X NA D Yes No X NA Yes No NA Yes D No 0 NA Turbine shutdown response time Is system programmed for fail -safe shutdown ?* Dyes No X NA Yes DNo X NA Yes No NA Yes No NA Was fail -safe verified to be operational?' D Yes No X NA Yes No X NA Yes No DNA 0 Yes D No 0 NA Wait time between applying pressure/vacuum /water and starting test: 30 MIN 30 MIN Test Start Time: 10:44 11:21 9:38 9:54 Initial Reading (R,): 2.312 2.306 1 3.413 3.412 Test End Time: 10:59 11:36 9:53 10:10 Final Reading (RF): 2.310 2.304 3.412 3.412 Test Duration: 15MIN 15MIN 15MIN 15MIN Change in Reading (RF -R,): 002 002 001 000 Pass/Fail Threshold or Criteria: 002 1 -.002 002 002 Test Result: X Pass Fail X Pass Fail Pass 0 Fail Pass Fail Was sensor removed for testing? X Yes No NA X Yes No DNA Yes D No DNA 0 Yes No NA Was sensor property replaced and verified functional after testing? X Yes No NA X Yes No NA D Yes No NA 0 Yes No 0NA Comments — (include information on repairs made prior to testing and recommendedfollow -upforfailedtests) ifthe entire depth ofthe sump is not tested, specify how much was tested. Ifthe answer to any of the questions indicated with an asterisk (*) is "NO" or "NA", the entire sump must be tested. (See SWRCB LG -l60) SWRCB, January 2002 7. UNDER - DISPENSER CONTAINMENT (UDC) TESTING x%347 fPageof Test Method Developed By: 0 UDC Manufacturer X Industry Standard 0 Professional Engineer Other (Specify) Test Method Used: 0 Pressure 0 Vacuum X Hydrostatic Other (Spec) Test Equipment Used: INCON TS -STS Equipment Resolution: UDC Manufacturer: UDC # UDC # UDC # UDC # UDC Material: UDC Depth: Height from UDC Bottom to Top of Highest Piping Penetration: Height from UDC Bottom to Lowest Electrical Penetration: Condition ofUDC prior to testing: Portion ofUDC Tested Does turbine shut down when UDC sensor detects liquid (both product and water )? 0 Yes No NA 0 Yes ONO NA 0 Yes 0 No 0NA Yes No 0 NA Turbine shutdown response time Is system programmed for fail- safe shutdown ?* 0 Yes No NA 0 Yes 0 No DNA 0 Yes No 0 NA Yes No NA Was fail -safe verified to be operational?* Oyes No NA Yes No NA 0 Yes 0 No 0 NA 0 Yes 0 No NA Wart time between applying pressure/vacuum/water and starting test NO UDCS Test Start Time: Initial Reading : Test End Time: Final Reading F): Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN Change in Reading (RF -&): Pass/Fail Threshold or Criteria: Test Result: 0 Pass 0 Fail Pass 0 Fail Pass Fail 0 Pass Fail Was sensor removed for testin ? 0 Yes No DNA 0 Yes 0 No NA Yes No 0 NA Yes 0 No DNA Was sensor properly replaced and verified functional after testing? 0 Yes 0 No NA 0 Yes No DNA 0 Yes 0No 0 NA Yes 0 No NA Comments — (include information on repairs made prior to testing, andrecommendedfollow -upforfailedtests) NO UDCS Ifthe entire depth ofthe UDC is not tested, specify how much was tested. Ifthe answer to - of the questions indicated with an asterisk ( *) is "NO" or "NA", the entire UDC must be tested. (See SWRCB LG -160) SWRCB, January 2002 8. FILL RISER CONTAINMENT SUMP TESTING 4M1WPage -17— of Facility is Not Equipped With Fill Riser Containment Sums 0 Fill Riser Containment Sumps are Present, but were Not Tested Test Method Developed By: 0 Sump Manufacturer X Industry Standard Professional Engineer Other (Spec) Test Method Used: Pressure Vacuum X Hydrostatic 0 Other (Specify) Test Equipment Used: INCON TS -STS Fill Sump # Fill Sump # Equipment Resolution: Fill Sump # Fill Sump # Sum Diameter: Sump De the Height from Tank Top to Top of7n Piping Penetration: Height from Tank Top to Lowest Electrical Penetration: Condition ofsump prior to testing: Portion of Sump Tested Sump Material: Wait time between applying pressure/vacuum/water and starting test: NOT TESTED Test Start Time: Initial Reading (R,): Test End Time: Final Reading Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN I5MIN 15MIN Change in Reading R, : Pass/Fail Threshold or Criteria: Test Result: Pass Fail 0 Pass Fail 0 Pass Fait 0 Pass Fail Is there a sensor in the sump? 0 Yes No Yes No 0 Yes 0 No 0 Yes No Does the sensor alarm when either product or water is detected? Yes No NA Yes 0No NA Yes No NA Yes No NA Was sensor removed for testing? 0Y s No NA Yes No NA 0Yes 0 No 0 NA Yes 0 No DNA Was sensor properly replaced and verified functional after testing? Yes 0 No NA Yes No NA Yes No NA Yes No NA Comments —(include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) NO FILL SUMPS SWRCB, January 2002 9. SPILL/OVERFILL CONTAINMENT BOXES yG3 7 fPage ;7 of ;Z Facility is Not Equipped With SpilUOverfill Containment Boxes Spill/Overfill Containment Boxes are Present, but were Not Tested Test Method Developed By: Spill Bucket Manufacturer X Industry Standard Professional Engineer Other (Specify) Test Method Used: Pressure Vacuum X Hydrostatic Other (Spec) Test Equipment Used: INCON TS -STS Equipment Resolution: Spill Box # Bucket Diameter: Spill Box # Spill Box # Spill Box # Bucket Depth: Wait time between applying pressure/vacuum/water and starting test: NOT TESTED Test Start Time: Initial Reading (Rj): Test End Time: Final Reading (RF): Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN Change in Reading (RF -RO: 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 recommendedfollow -upforfailed tests) SPILL BOXES TESTED DURING ANNUAL MONITORING CERT. 3o// / SB989 TESTING FAILURE REPORT SITE NAME: MEMORIAL HOSPITAL DATE: 5/7/12 THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE TESTING. REPAIRS: BOTH SUPPLY AND RETURN FOR EMERGENCY GENERATOR SECONDARY LIES FAILED. NO COMMUNICATION INSIDE BUILDING. PULLED 3/4 TEST PLUG OFF CLAM SHELL. DID NOT CHANGE GAUGES OUTSIDE. RETURN SHOWS PRESSURE OUTSIDE AT SUMP BUT FAILS INSIDE WHEN PRESSURED UP. SUPPLY FALLS RIGHT OFF WHEN NITROGEN FLOW IS SHUT OFF BOTH INSIDE AND OUT. THIS TANK IS GOING TO BE REMOVED SOMETEKE THIS SUNEKER. LABOR: PARTS INSTALLED: 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.