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HomeMy WebLinkAboutSB-989 2018CERS = 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 10132288 Date of Secondary Containment Test 10/17/2018 Business Name (Same as Facility Name or DBA-Doing Business As) VG MINI MARKET Business Site Address 6501 S Union Ave 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.) Bradley Hinsley Phone # (661)706 - 4321 Ext. Contractor/Tank Tester License # 971259 ICC Certification # 8373948 ICC Certification Expiration Date 8/23/2019 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID: (By tank number, stored product, etc.) A 87 B 91 C Diesel 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 5/6 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 RP1200-17 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 ICC Service Techican 8/23/2019 INCON STS 10/13/2019 VI. COMMENTS Provide any additional comments here. BOTH ANNULARS PASSED. 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 RP1200-17 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 8/23/2019 INCON STS 10/13/2019 Interstitial Communication Verification Method Used: VIII. COMMENTS Provide any additional comments here. ALL PRODUCT LINES FAILED. 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 RP1200-17 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 8/23/2019 INCON STS 10/13/2019 XVI. COMMENTS Provide any additional comments here. All 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 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 Gilbarco 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 RP1200-17 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 8/23/2019 INCON STS 10/13/2019 XXII. COMMENTS Provide any additional comments here. Dispenser 3/4 and 5/6 Failed. 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 UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action Installation Test Repair Test 12 Month Test I. FACILITY INFORMATION CERS ID 10132288 Date of Spill Container Test 10/17/2018 Business Name (Same as Facility Name or DBA-Doing Business As.) VG MINI MARKET Business Site Address 6501 S Union Ave 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.) Bradley Hinsley Phone # (661) 706 - 4321 Ext. Contractor/Tank Tester License # 971259 ICC Certification # 8373948 ICC Certification Expiration Date 8/23/2019 Spill Container Testing Training and Certifications (List applicable certifications.) 8/23/2019 III. SPILL CONTAINER TESTING INFORMATION Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) PEI RP1200-17 Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Tank ID: (By tank number, stored product, etc.) 87FB 91FB DieselFB 87VB Spill Container Manufacturer: OPW OPW OPW OPW Method of Cathodic Protection Non-Metallic Non-Metallic Non-Metallic Non-Metallic Isolation Isolation Isolation Isolation Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Inside Diameter of Spill Container: (Inches) 15" 15" 15" 15" Depth of Spill Container: (Inches) 18" 18" 18" 18" Does the spill container have a 5 gallon capacity? Yes No Yes No Yes No Yes No Method to Keep Spill Container Empty Drain Valve Drain Valve Drain Valve Drain Valve Onsite Pump Onsite Pump Onsite Pump Onsite Pump Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results Pass Fail Pass Fail Pass Fail Pass Fail V. COMMENTS All items marked “Fail” above must be explained in this section. Any additional comments may also be provided here. 87 Fill Bucket and Vapor Bucket Failed SB989 Testing. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached. CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council UNDERGROUND STORAGE TANK SPILL CONTAINER TESTING REPORT FORM (Page 1 of 1) Type of Action Installation Test Repair Test 12 Month Test I. FACILITY INFORMATION CERS ID 10132288 Date of Spill Container Test 10/17/2018 Business Name (Same as Facility Name or DBA-Doing Business As.) VG MINI MARKET Business Site Address 6501 S Union Ave 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.) Bradley Hinsley Phone # (661) 706 - 4321 Ext. Contractor/Tank Tester License # 971259 ICC Certification # 8373948 ICC Certification Expiration Date 8/23/2019 Spill Container Testing Training and Certifications (List applicable certifications.) 8/23/2019 III. SPILL CONTAINER TESTING INFORMATION Test Method Used: Manufacturer Guidelines: (Specify) Industry Code or Engineering Standard: (Specify) PEI RP1200-17 Engineered Method: (Specify) Attach the testing procedures and all documentation required to determine the results. # of Attached Pages Tank ID: (By tank number, stored product, etc.) 91VB Spill Container Manufacturer: OPW Method of Cathodic Protection Non-Metallic Non-Metallic Non-Metallic Non-Metallic Isolation Isolation Isolation Isolation Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Inside Diameter of Spill Container: (Inches) 15" Depth of Spill Container: (Inches) 18" Does the spill container have a 5 gallon capacity? Yes No Yes No Yes No Yes No Method to Keep Spill Container Empty Drain Valve Drain Valve Drain Valve Drain Valve Onsite Pump Onsite Pump Onsite Pump Onsite Pump Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) Other (Specify in section V.) IV. SUMMARY OF TESTING RESULTS Spill Container Test Results Pass Fail Pass Fail Pass Fail Pass Fail V. COMMENTS All items marked “Fail” above must be explained in this section. Any additional comments may also be provided here. VI. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the spill containers were tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.1 and all the information contained herein is accurate. UST Service Technician Signature If the facility has more components than this form accommodates, additional copies of this page may be attached.