HomeMy WebLinkAboutBCSD SB989 Retest - 89831CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, NA = Not applicable, UDC = Under-dispenser containment
UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6)
Type of Action Installation Test Repair Test Six Month Test 36 Month Test
I. FACILITY INFORMATION
CERS ID
Date of Secondary Containment Test 10/15/19 & 11/20/19
Business Name (Same as Facility Name or DBA-Doing Business As) Bakersfield City School District
Business Site Address 1501 Feliz Drive
City Bakersfield
ZIP Code 93307
II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Jerry Rangel
Phone # (661)327 - 9341 Ext.
Contractor/Tank Tester License # 998733
ICC Certification # 8900824
ICC Certification Expiration Date 08/19/21
III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS
Tank ID: (By tank number, stored product, etc.) A Unleaded B Diesel C D
Tank Containment
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Product Piping Containment
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Remote Fill Piping Containment
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Vent Piping Containment
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Vapor Recovery Piping Containment
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Turbine / Product Piping Sump
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Fill Riser Sump
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
Vent / Transition Sump ID: a b c d
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
UDC ID: 1 1/2 2 3/4 3 4
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
UDC ID: 5 6 7 8
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
UDC ID: 9 10 11 12
Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA
All items marked “Fail” or “N/A” must be explained in their respective “COMMENTS” section.
IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING
I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637 and all the information contained herein is accurate.
UST Service Technician Signature
ID = Identification
UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 2 of 6)
V. TANK CONTAINMENT TESTING INFORMATION
Manufacturer Identify Tank ID from section III for each Manufacturer
A B C D
A B C D
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages
Tank Containment Testing Training and Certifications (List applicable certifications.) Expiration Date
VI. COMMENTS
Provide any additional comments here.
VII. PRODUCT PIPING CONTAINMENT TESTING INFORMATION
Manufacturer Identify Tank ID from section III for each Manufacturer
APT A B C D
A B C D
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages
Product Piping Containment Testing Training and Certifications (List applicable certifications.) Expiration Date
ICC: 8900824 08/19/24
Interstitial Communication Verification Method Used:
VIII. COMMENTS
Provide any additional comments here.
ID = Identification
UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 3 of 6)
IX. REMOTE FILL PIPING CONTAINMENT TESTING INFORMATION Manufacturer Identify Tank ID from section III for each Manufacturer
A B C D
A B C D
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages
Remote Fill Piping Containment Testing Training and Certifications (List applicable certifications.) Expiration Date
Interstitial Communication Verification Method Used:
X. COMMENTS
Provide any additional comments here.
XI. VENT PIPING CONTAINMENT TESTING INFORMATION
Manufacturer Identify Tank ID from section III for each Manufacturer
A B C D
A B C D
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages
Vent Piping Containment Testing Training and Certifications (List applicable certifications.) Expiration Date
Interstitial Communication Verification Method Used:
XII. COMMENTS
Provide any additional comments here.
ID = Identification
UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 4 of 6)
XIII. VAPOR RECOVERY PIPING CONTAINMENT TESTING INFORMATION
Manufacturer Identify Tank ID from section III for each Manufacturer
A B C D
A B C D
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Vapor Recovery Piping Containment Testing Training and Certifications (List applicable certifications.) Expiration Date
Interstitial Communication Verification Method Used:
XIV. COMMENTS
Provide any additional comments here.
XV. TURBINE / PRODUCT PIPING SUMP TESTING INFORMATION
Manufacturer Identify Tank ID from section III for each Manufacturer
Unknown A B C D
A B C D
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages 1
Turbine / Product Piping Sump Testing Training and Certifications (List applicable certifications.) Expiration Date
Incon TS-STS 11/22/19
XVI. COMMENTS
Provide any additional comments here.
ID = Identification
UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 5 of 6)
XVII. FILL RISER SUMP TESTING INFORMATION
Manufacturer Identify Tank ID from section III for each Manufacturer
A B C D
A B C D
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages
Fill Riser Sump Testing Training and Certifications (List applicable certifications.) Expiration Date
XVIII. COMMENTS
Provide any additional comments here.
XIX. VENT / TRANSITION PIPING SUMP TESTING INFORMATION
Manufacturer Identify Vent / Transition Sump ID from section III for each Manufacturer
a b c d
a b c d
Test Method Used: Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Vent / Transition Piping Sump Testing Training and Certifications (List applicable certifications.) Expiration Date
XX. COMMENTS
Provide any additional comments here.
UDC = Under-dispenser containment, ID = Identification
UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 6 of 6)
XXI. UNDER-DISPENSER CONTAINMENT TESTING INFORMATION
Manufacturer(s): Identify UDC ID from section III for each Manufacturer
Unknown 1 2 3 4 5 6
7 8 9 10 11 12
1 2 3 4 5 6
7 8 9 10 11 12
Test Method Used:
Manufacturer Guidelines: (Specify)
Industry Code or Engineering Standard: (Specify)
Engineered Method: (Specify)
Attach the testing procedures and all documentation required to determine the results. # of Attached Pages 1 UDC Testing Training and Certifications (List applicable certifications.) Expiration Date
Incon TS-STS 11/22/19
XXII. COMMENTS
Provide any additional comments here.
If the facility has more components than this form accommodates, additional copies of these pages may be attached.
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