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HomeMy WebLinkAbout2020 SB989CERS = 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 10022956 Date of Secondary Containment Test 10/6/2020 Business Name (Same as Facility Name or DBA-Doing Business As) SAMCO California Business Site Address 4100 CALIFORNIA AVE City Bakersfield ZIP Code 93309 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Bradley Hinsley Phone # (661)706 - 4321 Ext. Contractor/Tank Tester License # 971259 ICC Certification # 8373948 ICC Certification Expiration Date 8/10/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID: (By tank number, stored product, etc.) A 87N B 91 C 87M D 87S 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 5/6 4 7/8 Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA UDC ID: 5 9/10 6 11/12 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 Unknown A B C D A B C D Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) PEI/RP1200-19 Sect. 4.2 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 INCON STS 10/9/2021 ICC Service Techican 8/10/2021 VI. COMMENTS Provide any additional comments here. VII. PRODUCT PIPING CONTAINMENT 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) PEI/RP1200-19 Sect. 5.3 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 Service Techican 8/10/2021 INCON STS 10/9/2021 Interstitial Communication Verification Method Used: VIII. COMMENTS Provide any additional comments here. 87M to 87S line and 87S product (lower) failed. 87S Syphon and Product (upper) and 87N Syphon and product lines could not be tested, new boots on order. 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) PEI/RP1200-19 Sect. 6.6 Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Turbine / Product Piping Sump Testing Training and Certifications (List applicable certifications.) Expiration Date ICC Service Techican 8/10/2021 INCON STS 10/9/2021 XVI. COMMENTS Provide any additional comments here. 87N STP Sump failed hydrostatic testing. Must be repaired and retested. All other STPs passed. 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 Unknown A B C D A B C D Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) PEI/RP1200-19 Sect. 6.6 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 ICC Service Techican 8/10/2021 INCON STS 10/9/2021 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) PEI/RP1200-19 Sect. 6.6 Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages UDC Testing Training and Certifications (List applicable certifications.) Expiration Date ICC Service Techican 8/10/2021 INCON STS 10/9/2021 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. CERS = 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 10022956 Date of Secondary Containment Test 10/6/2020 Business Name (Same as Facility Name or DBA-Doing Business As) SAMCO California Business Site Address 4100 CALIFORNIA AVE City Bakersfield ZIP Code 93309 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Bradley Hinsley Phone # (661)706 - 4321 Ext. Contractor/Tank Tester License # 971259 ICC Certification # 8373948 ICC Certification Expiration Date 8/10/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID: (By tank number, stored product, etc.) A Diesel B 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 2 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 Unknown A B C D A B C D Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) PEI/RP1200-19 Sect. 4.2 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 INCON STS 10/9/2021 ICC Service Techican 8/10/2021 VI. COMMENTS Provide any additional comments here. VII. PRODUCT PIPING CONTAINMENT 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) PEI/RP1200-19 Sect. 5.3 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 Service Techican 8/10/2021 INCON STS 10/9/2021 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) PEI/RP1200-19 Sect. 6.6 Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Turbine / Product Piping Sump Testing Training and Certifications (List applicable certifications.) Expiration Date ICC Service Techican 8/10/2021 INCON STS 10/9/2021 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 Unknown A B C D A B C D Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) PEI/RP1200-19 Sect. 6.6 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 ICC Service Techican 8/10/2021 INCON STS 10/9/2021 XVIII. COMMENTS Provide any additional comments here. Diesel Fill Sump failed hydrostatic testing. Must be repaired and retested. 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 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 UDC Testing Training and Certifications (List applicable certifications.) Expiration Date 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.