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SWRCB, January 2002 Page 1 ofL.
Secondary Containment Testing Report Form
Thisform is intendedfor use by contractorsperforming periodic testing ofUSTsecondary containment systems. Use the
appropriatepages ofthisform to report resultsfor all components tested. The completedform, written testprocedures, and
printoutsfrom tests (ifapplicable), shouldbe providedto thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: pate ofTestin
Facility Address: / 5Q5, dye-
Facility Contact: Phone:
Date Local Agency Was Notified of Testing:
Name of Local Aaencv Insnector tilnresent during testintyk
2. TESTING CONTRACTOR INFORMATION
Company Name:
Technician Conducting Test:
Credentials: 4CSLB Licensed Contractor U SWRCB Licensed Tank Tester
License Type: G a 3 License Number. e
Manufacturer Training
Manufacturer Component(s) Date Training_ Expires
3. SUMMARY OF TEST RFS1J1.TS
Component Pass Fail Not
Tested
Repairs
Made Component pis Fail Not
Tested
Repairs
Made
u u. u U U u
C 4— «s m U u u u u u
i .5 ty U U u 2- U U U
u U u U U U
0- S t. U U U J4 U U U
s & 04 u u u d u U u
04 u u U U u u
a tt s U U U U U U U
U U U U U U u
U U u u u U U
c KI U U U U U u u
U U u U U U u
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 fug compliance with legalrequirements
Technician's Signature: Date: /1L— 5;—,n%
C
SWRCB, January 2002
i
Test Method Developed By:
9
Page
4. TANK ANNULAR TESTING
U Tank Manufacturer ' .Industry Standard U Professional Engineer
U other (Specify)
I
2 ofLc
Test Method Used: U Pressure U Vacuum
U Other (Spec' )
J Hydrostatic
Test Equipment Used:
Is Tank Exempt From Testing ?
Tank # Tank #
U Yes U No U Yes U No
Equipment Resolution:
Tank # Tank #
U Yes U No U Yes U No
Tank Capacity:
Tank Material:
Tank Manufacturer.
Product Stored:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading (111):
iTest End Time:
Final Reading (RP):
Test Duration:
Change in Reading (RF-RO:
Pass/Fail Threshold or Criteria:
G t: U Pass U.Fall' U. Pm. U wl U Pass U ball !1 P;.Ma p t
Was sensor removed for testing? U Yes U No U NA UYes U No U NA U Yes U No U NA U Yes UNo U NA
Was sensor properly replaced and
verified functional after testing?
U Yes U No U NA U Yes U No U NA U Yes U No U NA U Yes U No U NA
Comments — include in onwdon on (' f repairs made prior to lesfittg, and recommendedfollow -upforjaded lesaj
I
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
Test Method Developed By:
f Test Method Used:
I
Test Equipment Used Q,,
U Piping Manufacturer Kjndustry Standard
U Other (Specify)
Kpressurc U Vacuum
U Other (Spedfv)
Piping
Page S oKG
U Professional Engineer
U Hydrostatic
Resolution:
7 Pining un aka_
Piping Material: r
Piping Manufacturer.
Piping Diameter: 2 '• 2"
Length of Piping Run: ` r
Product Stored: NLe \I
Method and location of
i in -run isolation:
Wait time between applying
pres=Wvacuurn/water and
starting test:
Test Start Time: rqjQ A,, 'fQ 14
Initial Reading (Rr): r
Test End Time:
Final Reading (RF):
Test Duration: 64 1 Ale Igg
Change in Reading (RF -Rr): 0-
Pass/Fail Threshold or
Criteria 2
Test Result:. Bess Lhiran i6a U Fart Pass U11*WL x Pass U »atl
Comments — (indude informadon on repairs made prior to testing, andrecommendedfollow-up forfailedtests)
Page '-( . of
Test Method Developed By. U Piping Manufacturer )(Industry Standard U Professional Engineer
U Other (Specs%' p)
Test Method Used: KPressme U Vacuum U Hydrostatic
U Other )
Test Equipment Used
Piping Material
Pipin an *s Pipin an a
Resolution:
Pipin Piping
Og
PipPiping Manufacturer: r
Piping Diameter y t f
c
Length ofPiping Run
Product Stored
Method and location of
i i isolation
Wait time between applying
pressure/vacuum/water and
starting test f la IhfA
Test Start Time 1924W f f
Initial Reading (RI).
Teat End Timm: z , f z ,
Final Reading (Rp): lyll
Test Dumflon:
Change in Reading (RP -RO:
Pass/Fail Threshold or
Criteria:
hest Resgl 9 : i6= U IM YL, i s U FkU Pass :Ei±
Comments -- (Include IirJormaor" on repairs mode priorto fisting: andreoammertdedfollm+ uPlorlailedtests)
Test Method Developed By: UPiping Manufacturer }Q Industry Standard U Professional Engineer
U Other )
Test Method Used p(Pressure UVacuum U Hydrostatic
U Other ('Specify)
Test Equipment Used 4t,
Piping . IGIS 07AIg Piping Yn # r 7a
Piping Material: ((
Equipment Resolution:
tug AW Wp Piping ue # rT it r
Q
Piping Manufacturer:- rn j r
Piping Diaameta-
Length ofPiping stun:
Product Stored:
Method and location of
in run isolation:
Wait time between applying
pressure/vacuum/water and
starting test: I'M 14
Test Stmt Time: UAA
Initial Reading (R&.
Test End Time:
Final Reading (RO:
Test Duration: RL INK
Change in (Rf-R1):
Pass/Fail T bmshold or
Criteria: 2 OXI
est$esel. U Ball IL! s U Fa11 Pass Lt $fail Pax , U Fail
Comments — lwrdude hfformatlon on r,epatrs madepriorto te&Ing, andn!EM ended: follow-erpforjailed testa)
6. PIPING SUMP TESTING
Test Method Developed By: U Sump Manufacturer Pndustry Standard U Professional Engineer
U Other (Specify)
Test Method Used: — —
Test Equipment Used co '`S
Page of (
Pressure
Ot:.cr 15
U Vacuum Hydrostatic
Equipment Resolution: 2
Sump # 't Sump # 3 ' Sump # Sump # rSumpMatcrial: " 77
S
I
Is system programmed for fail -safe
shutdown?*
Yes U No U NA14yes
r
Yes U No U NA
Height from Tank Top to Top of
Hi st Piping-Penetration: l " "
U No U NA
Height from Tank Top to Lowest
Electrical Penetration
Yes U No U NA
Condition of sump prior to testing:
4 41
i
Portion of Sump Tested' o
Does turbine shut down when
sump sensor detects liquid (both
nroduct and water) ?*
Xyes U No U NA X1'es U No U NA WYes U No U NA XYes U No U NA
Turbine shutdown response time S 3 Lrc-
Is system programmed for fail -safe
shutdown?*
Yes U No U NA14yes Yes UNo U NA Yes U No U NA is U No U NA
Was fail -safe verified to be
operational?*
U No U NA Yes U No U NA lS,j'es UNo U NA Yes U No U NA
Wait time between applying
pressure/vacuum/water and starting
test:
Test Start Time: 4 41 Z z,
Initial Reading (Rj): o
Test End Time: go f
Final Reading (RF): 9
Test Duration: 3
Change in Reading (RF -RO: t 11, 1242 i
Pass/Fail Threshold or Criteria:
Test Result: 1k, Pass, U Roil1. i.1*utw upoll R`aa E l' Iteil j Ps aa U Fall
Was sensor removed for testing? g Yes U No U NA Yes U No U NA b(Yes , U No U NA Yes U No U NA
Was sensor properly replaced and
verified functional after testing?
Yes U No U NA I.Yes UNo U NA gJ1Yes UNo U NA 49 Yes U No U NA
Comments — (include information on repairs made prior to testinz, and recommended follow -up for fartedtests)
Ifthe entire depth of the sump is not tested, specify how much was tested. If the answer to gtr y 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. PiPYNC CIiMP TFCTtNf_
Page 'I of
Test Method Developed By: U Sump Manufacturer )(Industry Standard U Professional Engineer
U Other (Sped)
Test Method Used: U Pressure U Vacuum )(Hydrostatic
U Ot:,er (Spec' )
Test Equipment Used: = TS —.57'S
Sump # Jt q Sump # tkiz
Sump Diameter: LYE'
Equipment Resolution:
Sump # Sump #
Sump Depth:
Sump Material: r4 P
Height from Tank Top to Top of
Highest Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition ofsump prior to testing:
Portion ofSump Tested' oto c°
Does turbine shut down when
sump sensor detects liquid (both
roduct and water)?*
p9,Yes U No U NA Yes UNo VNA UYes U No U NA U Yes U No U NA
Turbine shutdown response time
Is system programmed for fail -safe
shutdown ?*
KYes U No U NA UYes U No )QNA. U Yes UNo U NA U Yes U No UNA
Was fail -safe verified to be KYes U No U NA UYes U No NA U Yes UNo U NA U Yes U No UNA
operational?'
Wait time between applying
pressure/vacuum/water and starting
test: 10 1104 6 A14
Test Start Time:
Initial Reading (Ri): U
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF-Rj:
Pass/Fail Threshold or Criteria:
T st:Resultc: Pass U Evil .` Psis -., W Fall, U'.:F!as9 :. U`Irall U Pasa U Fail.:,
Was sensor removed for testing? Yes U No U NA A,Yes U No U NA U Yes U No U NA UYes UNo U NA
Was sensor properly replaced and
verified ftinctional after testin ?
9,Yes U No U NA Ryes UNo U NA U Yes U No UNA U Yes U No U NA
Comments — (include information on repairs made prior to testing, and recommendedfollow -up forfailed tests)
l v,st tr,n S;j *,-5- 11 aay ",j4 UU S - Ans n. S4M_ 4 aA d- , #$at s:1azj talc _
t Ifthe entire depth of the sump is not tested, specify how much was tested. If the answer to my of the questions indicated with an
asterisk (') is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG =160)
Test Method Developed By:
e e
t- DISPENSER CONT
U UDC Manufacturer
U Other (Specify)
Page 9 OfP
U Industry Standard U Professional Engineer
Test Method Used: U Pressure U Vacuum
U Other (Specg.)
U Hydrostatic
Test Equipment Used:
UDC # UDC #
Equipment Resolution:
UDC # UDC #
UDC Manufacturer.
UDC Material:
UDC Depth:
Height from UDC Bottom to Top
ofHighest Piping Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition of UDC prior to
testing:
Portion of UDC Tested
Does turbine shut down whenf. UDC sensor detects liquid (both U Yes U No U NA U Yes U No UNA
prod and water)?*
U Yes U No U NA UYes U No U NA
Turbine shutdown response time
is system programmed for fail- U Yes U No U NA
safe shutdown ?. U Yes U No U NA UYes U No U NA U Yes U No U NA
Was fail -safe verified to be U Yes U No U NA
operational ?' U Yes U No U NA
i
UYes UNo U NA UYes U No U NA
Wait time between applying
presswe/vacuum/water and
starting test
Test Start Time:
Initial Reading Ri :
Test End Time:
Final ReadingRF
Test Duration:
Change in Reading
Pass/Fail Threshold or Criteria:
I Test Result; U ft t1' U Paas U Fars: U Iil U Van Up*
Was sensor removed for testing? U Yes U No U NA U Yes U No U NA U Yes UNo U NA U Yes UNo U NA
Was sensor properly replaced and U Yes U No U NA U Yes U No U NAverifiedfunctionalaftertesting? U Yes U No U NA U Yes U No UNA
Comments — (include information on repairs made prior to testing, and recommendedfollow- upforjalledtests) i
I
egrl 04 6A ' t yAC's
Ifthe entire depth ofthe UDC is not tested, specify how much was tested. If the answer to rM of the questions indicated with an
asterisk M is "NO" or "NA ", the entire UDC must be tested (See SWRCB LG -160)
i
iI`
SWRCB, January 2002 Page ofo
S. FILL RISER CONTAINMENT SUMP TESTING
Facility is Not Equipped With Fill Riser Containment Sumps
Fill Riser Containment Sumps are Present, but were Not Tested U
Test Method Developed By. U Sump Manufacturer U Industry Standard U Professional Engineer
U Other (Specify)
Test Method Used: U Pressure U Vacuum U Hydrostatic
Specify) U Other '
Test Equipment Used: Equipment Resolution:
FM Sump# Fill Sum # Fill Sump # Fill Sump #
Sivnn Diameter
um D the
eight from Tank Top to Top of
i est Pi in Penetration:
Electrical
eight from Tank Top to Lowest
Penetration-
Condition of sump prior to
testing:
Portionof Sump Tested
Sump Material:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Readin
Test End Time:
Final Read' Rf :
Test Duration:
Change in Reading
Pass/Fail Threshold or Criteria:
Test Result: U. s. U. __ - U go" U.Ba t U Lisa U Fall U .. Li F-01
Is there a sensor in the sump? U Yes U No U Yes U No U Yes U No U Yes U No
Does the sensor alarm when
either product or water is
detected?
U Yes U No U NA U Yes U No U NA UYes U No U NA U Yes UNo U NA
Was sensor removed for testing? U Yes U No U NA U Yes UNo U NA U Yes U No U NA U Yes U No U NA
Was sensor properly replaced and
verified functional after testing?
U Yes U No U NA
UYes U No U NA U Yes U No U NA U Yes U No U NA
Comments —(include information on repairs made prior to testing, and recommendedfo!!ow -upforfailedtests)
SWRCB, January 2002
9. SPILLOVERFILL CONTA
Facili is Not Equipped With Spill/Overfill Containment Boxes U
i S i1VOverfill Containment Boxes are Present, but were Not Tested U
Test Method Developed By- U Spill Bucket Manufacturer
j U Other (Spec)
Test Method Used: U Pressure
U Other (S ec)s )
Test Equipment Used
f
U Vacuum
l Sp Ill Box # Sp Ill Box #
Bucket Diameter: •+
Bucket Depth: +`
Wait time between applying
Page ( 0 ofit
Standard U Professional Engineer
KHydrostatic
quipment Resolution:
SvIli Box # spW Box #
starting test:
Test Start Time:
Initial Reading (R,):
Test End Time: 9;
Final Reading (RF): 8
Test Duration:
Change in Reading (RF-RJ:
Pass/Fail Threshold or
Criteria: Y
dgf'$esulle Pass U hail U R*ss U hall U Pass U Frail U 'mss U b'ai1
Comments — (Oclude information on repairs made prior to testing, and recommendedfollow- upforfailed tests)