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Secondary Containment Testing Report Form
Thisform is intendedfor use by contractors performingperiodic testing of USTsecondary containment systems. Use the
appropriatepages 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 INFORMATMN
2. TF.gTYNG C ONTRAC'TC)R YNFORN4ATFnN
Company Name.
Facility Name: (41 Date of Testing: _
Technician Conducting Test:
Facility Address:
Credentials: Q'CSLB Licensed Contractor
Facility Contact: 4, Ci Phone:
License Number.
Manufactyrer Trainine
Component(s) Date Training Expires
Date Local Agency Was Notified of Testing:
Name ofLocal Agency Inspector (fpresent during testing):
2. TF.gTYNG C ONTRAC'TC)R YNFORN4ATFnN
Company Name.
Technician Conducting Test:
Credentials: Q'CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
License Type:
WWWONAM
Manufacturer
License Number.
Manufactyrer Trainine
Component(s) Date Training Expires
3. SUMMARY OF TEST RF.WT.TS
If hydrostatic testing was performed, describe what was done with the water after completion of tests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the facts st I in this document are accurate and in full compliance witlt legal requirements
Technician's Signature: Date: /Z 2 %— 02
a
Component
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1 aino or r.o
oor o nc r..
nor o r.noo
ana o r r. o
ninaoo onoo
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If hydrostatic testing was performed, describe what was done with the water after completion of tests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the facts st I in this document are accurate and in full compliance witlt legal requirements
Technician's Signature: Date: /Z 2 %— 02
a
4. TANK ANNULAR TR.RTtN(:
Page —Z— of
Test Method Developed By: 0 Tank Manufacturer ndustry Standard Professional Engineer
Other (Specie)
Test Method Used: Pressure 2"Vacuum 0 Hydrostatic
Other (Specie)
Test Equipment Used: Equipment Resolution:
Tank # g1,2 L Tank # Tank # Tank #
Is Tank Exempt From Testing ?' 0 Yes &<O Yes No 0 Yes No 0 Yes 0 No
Tank Capacity:
Tank Material: rzte
Tank Manufacturer: v
Product Stored:
Wait time between applying
pressure/vacuum/water and
starting test
Test Start Time: q
Initial Reading (Rj):
Test End Time: IQ 40
Final Reading (RP);
Test Duration:
Change in Reading (RF -EQ:
Pass/Fail Threshold or Criteria:
esr tesulk:; PTass 0 Fail'. Pttiss: Q-Ti l 0 Pass D Bail Pass Fall
Was sensor removed for testing? des 0 No NA Yes No DNA, Yes No 0NA 0 Yes 0No NA
Was sensor properly replaced and
verified functional after testing?
es No 0 NA 0 Yes No 0 NA 0Yes No NA Yes 0 No NA
Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed 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 ofRegulations, Title 23, Section 2637(a)(V
SWRCB, January 2002
S_ CvroNT)Anv PTPF TR_CTINr'
Page ? of 7
Test Method Developed By: 0 Piping Manufacturer &ndustry Standard 0 Professional Engineer
0 Other (Spec)
Test Method Used: Erfrr-essure 0 Vacuum 0 Hydrostatic
0 Other (Spec)
Test Equipment Used: ,'y co, Agsigg, Equipment Resolution:
Piping Run # Piping Run # Piping Run # Piping Run #
Piping Material: ra
Piping Manufacturer:
Piping Diameter:
Length of Piping Run:
Product Stored:
Method and location of
piping-run isolation:
Wait time between applying
pressure/vacuum /water and
starting test:
Test Start Time:
Initial Reading (RI):
Test End Time;
Final Reading (RF):
Test Duration:
Change in Reading (RF -ice:
Pass/Fail Threshold or
Criteria: p, z
Tes ResultV ss O T+aii R °Pass Fall,. G Pass ftfl 0 Pass O Rail
Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
Test Method Developed By: 0 Sump Manufacturer ndustry Standard 0 Professional Engineer
0 Other (Spec)
Test Method Used: 0 Pressure 0 Vacuum RA ydrostatic
0 Other (Specie)
Test Equipment Used: s Equipment Resolution:
Sump # Sump # Sump # Sump #
Sump Diameter:
Sump Depth:
Sump Material:
Height from Tank Top to Top of
Highest Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to testing:
Portion ofSump Tested'
Does turbine shut down when
sump sensor detects liquid (both
induct and water)? .
O'Yes 0 No DNA D Yes No DNA 0 Yes No DNA 0 Yes No 0 NA
Turbine shutdown response time 1 S
Is system programmed for fail -safe
shutdown ?*
917'e-s No 0 NA D Yes D No DNA 0 Yes []No DNA D Yes No 0 NA
Was fail -safe verified to be
o erationalf
0,1e-s 0 No 0 NA 0 Yes DNo DNA Yes No DNA 0 Yes 0 No 0 NA
Wait time between applying
pressure /vacuum/water and starting
test:
Test Start Time:
Initial Reading (Ri):
Test End Time:
Final Reading (RF): q
Test Duration:
Change in Reading (RF -R{):
Pass/Fail Threshold or Criteria:
Test.Results: Pass Faal, .. D Pass %'ail TZ. Piss:. O D Pass: D Fail
Was sensor removed for testing? eTes 0 No NA 0 Yes 0No 0 NA 0 Yes 0 No NA 0 Yes 0 No 0NA
Was sensor properly replaced and
verified functional after tesdn ?
pes D No 0 NA 0 Yes 0No 0 NA 0 Yes D No NA 0 Yes 0 No 0 NA
Comments — (include information on repairs made prior to testing, and recommendedfollow -upfbrfailed tests)
r.
t If the 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)
I •
J
I
SWRCB, January 2002
7. iTN F.R_17TfiPF.NCFR rnNTe rnrna nrr rrrnr, -r errivr_
Page - ofd
Test Method Developed By: UDC Manufacturer &Wdustry Standard 0 Professional Engineer
0 Other (Spec)
Test Method Used: Pressure 0 Vacuum drostatic
0 Other (Spect&)
Test Equipment Used: 7-5—s Equipment Resolution:
UDC # UDC # _ UDC # UDC #
UDC Manufacturer.
UDC Material:
UDC Depth: 26 "
Height from UDC Bottom to Top
ofHighest Piping Penetration: 9'
Height from UDC Bottom to
Lowest Electrical Penetration:
Et-& 'r-s C n
ss
Condition of UDC prior to
testing:
Portion ofUDC Tested
Does turbine shut down when
UDC sensor detects liquid (both
induct and water)?*
No .NA No NA 0 Yes D No 0 NA Dyes No NA
Turbine shutdown response time
Is system programmed for fail-
safe shutdown ?*
s 0 No C NA Yes 0 No 0NA Yes D No 0 NA Yes No NA
Was fail -safe verified to be
operational?*
D No 0 NA 0 No DNA 0 Yes 0No NA 11 Yes 0 No NA
Wait time between applying
pressure/vacuum/water and
startin test
Test Start Time:
Initial Reading
Test End Time:
Final Reading F :
Test Duration:
Change in Reading Ri
Pass/Fail Threshold or Criteria:
est;Resulf: mss ;Fitil :..:.: L9`as O:Tall Or Pass:. r:T+AII ,: f7'ss: [J;Fail
Was. sensor removed for testing? LOYes 0 No 0 NA P-Ye -s 0No 0 NA Yes D No 0 NA 0 Yes No D NA
Nas sensor properly replaced and
verified, functional after testin ?
es No Q NA 0 No 0 NA 11 Yes No NA 0 Yes No 0 NAr}'
QrY
Comments - (include information on repairs made prior to testing, and recommendedfollow -upforjailed tests)
If the entire depth ofthe UDC is not tested, specify how much was tested Ifthe answer to My ofthe questions indicated with an
asterisk ( *) is "NO" or "NA ", the entire. UDC must be tested. (See SWRCB LG -160)
Facility is Not Equipped With Fill Riser Containment Sums 81,
Fill Riser Containment Sumps are Present, but were Not Tested 0
Test Method Developed By: Sump Manufacturer Industry Standard Professional Engineer
0 Other (Spec)
Test Method Used: 0 Pressure 0 Vacuum 0 Hydrostatic
Other (Spec)
Test Equipment Used: Equipment Resolution:
Fill Sump Fill Sum # Fill Sump # Fill Sump #
Sump Diameter:
Sump Depth:
Height from Tank Top to Top of
Highest Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to
testing:
Portion of Sump Tested
Sump Material:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial ReadingR
Test End Time:
Final Reading RF ):
Test Duration:
Change in Reading R Rt :
Pass/Fail Threshold or Criteria:
Test Result: 0 Pass O Fail Pass Fail Pass Faih D Pass Fail
Is there a sensor in the sump? Yes 0 No 0 Yes 0 No 0 Yes 0 No Yes 0 No
Does the sensor alarm when
either product or water is
detected?
D Yes 0 No 0 NA Yes No NA 0 Yes 0 No 0 NA 0 Yes 0 No 0 NA
Was sensor removed for testing? Yes 0 No DNA D Yes No NA 0Yes 0 No 0NA Yes No NA
Was sensor properly replaced and
verified functional after testing?
Yes No NA Yes D No DNA Yes No NA Yes No NA
Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
Facility is Not Equipped With Spill/Overfill Containment Boxes
Spill/Overfill Containment Boxes are Present, but were Not Tested
Test Method Developed By: 0 Spill Bucket Manufacturer &Hndustry Standard Professional Engineer
Other (Spec)
Test Method Used: 0 Pressure Vacuum oHly—drostatic
Other (Specify)
Test Equipment Used: e., m pTs Equipment Resolution: 2j
Spill Box # $ 7 Spin Box # Spill Box # Spill Box #
Bucket Diameter: Z "
Bucket Depth:
Wait time between applying
pressure /vacuum/water and
starting test:
Test Start Time: 91 ff9
Initial Reading (111):
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF-RI):
Pass/Fail Threshold or
Criteria:
Test Result: less 0 Fall Pass Fail 0 Pass 1±a1G Pass 0 Fair
Comments — (include information on repairs madeprior to testing, and recommendedfollow upforfailedtests)
Permit to Operate
To Be Posted
Hazardous Material/ Hazardous Waste Unified Permit
CONDITIONS OF PERMIT ON REVERSE SIDE
PERMIT ID #015 - 021- 002768 This permit is issued for the following:
BAKERSFIELD POLICE DEPARTMENT
1601 TRUXTUN AVENUE
BAKERSFIELD CA 93301
Hazardous Materials Plan
Hazardous Waste Generator and /or Treatment
Underground Storage of Hazardous Materials
TANK HAZARDOUS CAPACITY UNITS YEAR TANK TYPE TANK MATERIAL TANK MONITOR PIPING METHOD PIPING MONITOR
SUBSTANCE INSTALLED
0001 REGULAR 15000 GAL 1995 DOUBLE FIBERGLASS INTERSTITIAL PRESSURE AUTOMATIC LEAK
ALL MONITORING DETECTION
Issued by:
B E R S F I D
FIRE
ARIA/ r
Bakersfield Fire Department
PREVENTION SERVICES DIVISION
2101 H Street
Bakersfield, CA 93301
Phone 661- 326 -3979
FAX 661 - 852 -2171
Approved by:
Howard H. Wines, III, Director
Prevention Services Division
Issue Date: July 1, 2009
Expiration Date: June 30, 2012