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Home My WebLink About1129 UNION AVENUE (3)SWRCB, January 2002 Page of A Secondary Containment Testing Report Form Thisform is intendedfor use by contractors performing periodic testing of UST secondary containment systems. Use the appropriatepages ofthisform to report resultsfor all components tested. The completedform, written test procedures, and printoutsfrom tests (fapplicable), should be provided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: J 17-2 Date of Testing: / TZe/ o Facility Address: t'j , Facility Contact: Phone: Date Local Agency Was No feed ofTesting: / U Name of Local Agency Inspector (ifpresent during testing): 2. JESTING CONTRACTOR INFORMATION Company Name: (1 r Technician Conducting Test: Not Tested Credentials: CSLB_LAcensed Contractor SWRCB Licensed Tank Tester License Type: License Number: — Manufacturer Manufacturer Training Component(s) Date Training Expires e x 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Rcpairs Made e x x vP 57-r 7 If hydrostatic testing was perfo7ed, desAribe what was done with the water after completion of tests: U, CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best ofmy knowledge, thefacts state in this document are accurate and infull compliance with legs requirements Technician's Signature: Date: ) V SWRCB, January 2002 4. TANK ANNULAR TE L Page of Test Method Developed By: Tank Manufacturer Industry Standard Professional Engineer Other (Specify) Test Method Used: Pressure Vacuu Hydrostatic Other (Specify) Test Equipment Used: Equipment Resolution: 12 A Tank # Tank # Tank Tank 67 Is Tank Exempt From Testing?' Yes Yes o Yes Q'_L Yes Tank Capacity: Tank Material: Tank Manufacturer: S A^1 S Product Stored: a 7 Wait time between applying pressure /vacuum/water and starting test: S ' Test Start Time: 2 0 7 1 L 5 C Initial Reading (R,): 0a Test .End Time: v a— 71C Final Reading (RF): gyp. S Test Duration: Change in Reading (RF -R,): L1217 Pass/Fail Threshold or Criteria: Test Result: ass Fail Pass Fail Pas Fail Fail Was sensor removed for testing? No NA es No NA es • No NA Y No NA Was sensor properly replaced and verified functional after testing? Yes NA Yes NA Yes NA Yes Q NA Comments — (include information on repairs madeprior to testing, and recommendedfollow -up forfailed tests) 1 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)1 SWRCB, January 2002 6. PIPING SUMP TE I Page 7 of Test Method Developed By: Sump Manufacturer ustry Standa Professional Engineer Other (Specie) Test Method Used: Pressure Vacuum Hydros tic Other (Specify) Used: —f - I f Z —S Equipment Resolution: oTestEquipment eter: Sump # "6 7 5, Sump* 9 46L Sump # 57 ., Sump # y f Sump Material: L Height from Tank Top to Top of Highest Piping Penetration: LA LL 7 Z Height from Tank Top to Lowest Electrical Penetration: Z' Z Condition of sump prior to testing: Portion of Sump Tested 11Z Does turbine shut down when sump 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 o erational ?* Yes No NA Yes No NA Yes No NA Yes No NA Wait time between applying pressure /vacuum/water and starting test: D, M I V ' I iM J/1 J i1l r } C I/ V40 Test Start Time: Initial Reading (Rj): yW_06 t?j 0, `?q3 Test End Time: St(a L ; " Z/ f Final Reading (RF): p 0, 0,51Z- c? 9U Test Duration: t f ih n , %t 7 Change in Reading (RF -Rj): p too vcJ I ' oZ rry) S Pass/Fail Threshold or Criteria: of, L) cx7 Z Test Result: Pass Fail Pass Fa' Pas Fail Pass Fa 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) If the entire "depth of the sump 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 sump must be tested. (See SWRCB LG -160) SWRCB, January 2002 6. PIPING SUMP TESTING Page _R_ of Test Method Developed By: Sump Manufacturer . Industr .tandard—' Professional Engineer Other (Specify) Test Method Used: Pressure Vacuum dro lahc Other (Specify) Test Equipment Used: — S' Equipment Resolution: Sump Diameter: Sump # C Sump # k Sump # Sump # A Sump Depth: 1_ t Sump Material: Height from Tank Top to Top of Hi h6 Piping Penetration: Z Might from Tank Top to Lowest Electrical Penetration: 7i 7i Condition of sump prior to testing: Portion of Sump Tested' Does turbine shut down when sump 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: T Z./ S Qfc 3 jZ Initial Reading (R,): Q 5-61-6 Test End Time: t 2 ; O t- Final Reading (RF): j Test Duration: 6n r" niP rM,ll Sa,,%i Change in Reading (RF -R,): Pass/Fail Threshold or Criteria: Test Result: ass Fail Fail Pass Fail Pass Fail Was sensor removed for testing? Ye 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 recommendedfollow -upfor.failed tests) If the entire depth ofthe sump is not tested, specify how much was tested. If the answer to May of the questions indicated with an asterisk ( *) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160)