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HomeMy WebLinkAbout3500 GILMORE AVENUE (3)ARSftTi- Iii a /T, an. AT: i: UNE ft R'? CIL uNE ft CPS, -Wm' > 359-0 Gilmre awe sfjejd,. CA 933" PUI%6i - 327 -9341 p,arx#6b1- 325 -255V ems.: THE COI ONCONSWC M FMOst. tW lp?gVMAp } -"Mal I Waq pUAK dtv+ae tsae vckr+e ct(ttoeteat9aoe (t6 ssl•q 1 Efiy 0.3 1. vrs wWa rm ea otaaaa ess:per rr+cseto gras ssDarao r. - The Oxwenion conshmmoovevamm a4a vashOmjo w. Nis C3AAMEPA'S: COMMEW: COklM I declare under penalty of perjury that I ate a licensed tank tester In the State of California and that the Information contained In this report Is true and correct to the bast of my knowledge. . SWRCB, January 2002 0 Page / Of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (:f applicable), should be provided to the facility owner /operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility 0 0& Date of Testing: Facility Address: Facility Contact: 1 Date Local Agency Was Notified of Testing: SWRCB, January 2002 0 Page / Of Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (:f applicable), should be provided to the facility owner /operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility 0 0& Date of Testing: Facility Address: Facility Contact: Phone: Date Local Agency Was Notified of Testing: Name ofLocal Agency Inspector (fpresent during testing): 2. TESTING CONTRACTOR INFORMATION Com any Name: ZOO Technician Conducting Test: Credentials: @,CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: Manufacturer License Number. Manufacturer Training Com onent s Date Training Expires WA nnnn 3. SUMMARY OF TEST RESI7LTS Component ZOO nnnn nnannn nn n nin n n nrnnn inn n n h fn nn n ntnn nn nnn noon onoo ra000 nninnn nraoo, ono© ra000 nnc n: nnoo rnnr.rn Ifhydrostatic 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 ofmy knowledge, thefacts sla , in this document are accurate and infull compliance wills legal requirements Technician's Signature: Date: /Z- 2 %- o SWRCB, January 2002 d_ TANK ANNTTY.AR TFCTiNf_ Page o of —2 Test Method Developed By: Tank Manufacturer DIndustry Standard Professional Engineer Other (Sped) Test Method Used; Pressure FXI Facuum Hydrostatic Other (Sped) Test Equipment Used: Equipment Resolution: Tank # g, 7 Tank # Tank # Tank # Is Tank Exempt From Testing ? Yes &<O Yes No Yes No Yes No Tank Capacity: Tank Material: Tank Manufacturer: Product Stored: Wait time between applying pressure/vacuum/water and starting test: Test Start Time: q Initial Reading (RI): Test End Time; Final Reading (RF): Test Duration: Change in Reading (RF -R,): Pass/Fail Threshold or Criteria: esC 'esuitk Pass I+'aft;. 1'`r 9s Q'%a l` ' 0, Pass. p Fiiil; Pass ha'R : Was sensor removed for testing? VIes No NA Yes No NA. Yes No NA Yes No NA Was sensor properly replaced and verified functional after testin ? es No NA Yes No NA Yes No NA Yes No NA Comments — (include information on repairs made prior to testing, and recommendedfollow -upjorfailed 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)(6)1 5_ gRrC)NnARV PYPF TFCTINr n Page '? of 7 Test Method Developed By: 0 Piping Manufacturer &I'ndustry Standard 0 Professional Engineer 0 Other (Specify) Test Method Used: e1rressure Vacuum Hydrostatic 0 Other (Specify) Test Equipment Used: A,y ,-, Equipment Resolution: 1 Piping Run # Piping Run # Piping Run # Piping Run # Piping Material: 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 (R,): Test End Time: Final Reading (RF): Test Duration: Change in Reading (RF-Ro: Pass/Fail Threshold or Criteria: p, 2 teuT. ss O: ;Pass FF4 0 Pass 0)t+ll:. . Comments —(include Information on repairs made prior to testing, andrecommendedfollow -upforfailed tests) SWRCB, January 2002 6. PIPING SUMP TF.CTfNC. Page 4y of Test Method Developed By: Sump Manufacturer 4r6dustry Standard 0 Professional Engineer 0 Other (Specl ) Test Method Used: Pressure 0 Vacuum &trydrostatic Other (Spec) Test Equipment Used: 5 _ 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 ofsump prior to testing: Portion of Sump Tested' 41, ° o Does turbine shut down when sump sensor detects liquid (both product and water)?* des 0 No DNA 0 Yes 0No 0 NA Yes No 0 NA Yes D No DNA Turbine shutdown response time 1 S Is system programmed for fail -safe shutdown? 44-1re-s No D NA Yes 0No 0 NA DYes No NA Yes No 0 NA Was fail -safe verified to be operational?* mimes No 0 NA D Yes 0 No NA 0 Yes 0No NA 0 Yes 0 No DNA Wait time between applying pressure /vacuum/water and starting test: Test Start Time: Initial Reading (Ri): Test End Time: Final Reading (RF): 7 Test Duration: Change in Reading (RF -Rj): Pass/Fail Thresbold or Criteria: ja Teat .Result:. Puss. d r1'. Pas§ 0•5il Q Pass:. 0Fa14- 0 Pass 0Fail Was sensor removed for testing? P"res 0 No DNA Yes 0 No DNA oyes 0 No NA 0Yes 0 No D NA Was sensor properly replaced and verified functional after testing? PoYes 0 No 0 NA 0 Yes 0 No O NA Yes 0 No 0 NA 0Yes 0 No NA Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) is Ifthe entire depth of the sump is not tested, specify how much was tested. Ifthe answer to my ofthe questions indicated with an asterisk ( *) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160) 0 SWRCB, January 2002 7. UNDER - DISPENSER CnNTAINMTi.NT (tinrl TFCTIN(7 Page _57 of Test Method Developed By: 0 UDC Manufacturer 0 Other (Speci ) LHfdustry Standard 0 Professional Engineer Test Method Used: 0 Pressure 0 Other (Specify) 0 Vacuum 2'ifydrostatic Test Equipment Used: 7-5__S Equipment Resolution; UDC # UDC # _ UDC # UDC # AMC Manufacturer. UDC Material: UDC Depth: 2-6 " Height from UDC Bottom to Top of Highest Piping Penetration; 9 Height from UDC Bottom to Lowest Electrical Penetration: Ej-r_ • CA I Cn f Oo Condition of UDC prior to testing: Portion of UDC Tested Does turbine shut down when UDC sensor detects liquid (both product and water)?* 5-Ye—s 0 No 0 NA C-YM 0No 0NA D Yes 0 No 0 NA 0 Yes 0No 0 NA Turbine shutdown response time Is system programmed for fail- safe shutdown?. s 0 No 0 NA EYe-s ONo DNA OYes ONo ONA OYes ONo DNA Was fail-safe verified to be operational?' i s D No 0 NA OPY-s 0No DNA D Yes 0 No DNA 0 Yes 0 No 0 NA Wait time between applying pressure/vacuum/water and startinR test Test Start Time: Initial Reading : Test End Time: Final Reading F : Test Duration: Change in Reading F-R : 10, co Pass/Fail Threshold or Criteria: hest Resulfr rasa 01iill.; S ' . D Hill Q: Pass Was. sensor removed for testing? t8'Yes 0 No 0 NA Ills C No DNA 0 Yes 0 No 0 NA 0 Yes 0No 0 NA Vas sensor properly replaced and verified, functional after testing? es 0 No DNA Qr res 0 No D NA 0 Yes 0 No 0 NA 0 Yes 0 No 0 NA Comments — (include information on repairs made prior to testing, and recommendedfollow- upforfailed tests) 1 If the entire depth of the UDC is not tested, specify how much was tested. If the answer to M of the 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 1, Fill Riser Containment Sumps are Present, but were Not Tested 0 Test Method Developed By: 0 Sump Manufacturer 0 Industry Standard 0 Professional Engineer 0 Other (Spec) Test Method Used: 0 Pressure 0 Vacuum 0 Hydrostatic 0 Other (Spec) Test Equipment Used: Will Sum # Fill Sump # Sump Diameter: Equipment Resolution: Fill Sump # Fill Sump # 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 Reading Rr : Test End Time: Final Reading RF ): Test Duration: Change in Reading R R, : Pass/Fail Threshold or Criteria: Test Result: Pass Faff 0 Pass 0 Fail 0 Pass O,FaiF 0 Pass D Fait Is there a sensor in the sump? Yes 0 No 0 Yes 0 No Yes 0 No Yes No Does the sensor alarm when either product or water is detected? 0 Yes 0 No 0 NA 0 Yes 0 No NA 0 Yes 0 No 0 NA 0 Yes 0No 0NA Was sensor removed for testing? Yes D No 0 NA D Yes No NA D Yes 0 No DNA Yes DNo NA Was sensor properly replaced and verified functional after testing? 0 Yes No 0 NA 0 Yes No NA DYes D No 0 NA Yes No 0N Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) 9. SPILTJOVERFILL CONTAINMENT BOXES 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 KIfidustry Standard Professional Engineer 0 Other (Spec) Test Method Used: Pressure 0 Vacuum 9-Ky'—drostatic 0 Other (Spec) Test Equipment Used: Equipment Resolution: zj Spill Box # % Spill Box # Spill Box # Spill Box # Bucket Diameter: Z" Bucket Depth: Wait time between applying pressure/vacuum/water and starting test: Itl go Test Start Time: Initial Reading (R,): Test End Time: Final Reading (RF): Test Duration: Change in Reading (RF -R,): Pass/Fail Threshold or Criteria: Test Wsult: Mass 0 Fail Rass Fafd Pass Tall. Pass Fail Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)