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Home My WebLink AboutSB-989 2019UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1of 6) Type ofAction fl lnstallation Test E Repak Test E six Month Test I 36 Month Test I. FACILITYINFORMATION CERS ID 10024186 Dats of Secondary conlainment TeBt 01118t19 Business Name (Same as Facility Name or DBA-Doing Business As) Brookside Market & Deli Buslness Site Address 4700 Coffee Road City Bakersfield ZIP Code 93308II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Perform,ng the Test (Prht as s/,own on the ICC Ceftification.) Jerry Rangel Phone # (661)327 - 9341 Ex. Contractor/Tank Tester License # 998733 ICC Certification # 8160834 ICC Certification Expiration Date o8t24t19 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS lank lDt (By tank number, stored product, etc.)A87A B87B c91 D Diesel Tank Containment Tightness Test Result El pass E Fait E ttA El Pass n Fair I NA B eass ! Fait n NA El Pass E Fail E NA Product Piping Containment Tightness Test Result EX pass E Fait E NA B eass E Fait E NA EI Pass fl Fait E NA I Pass E Fait E NA Communication Test Result ffi eass I Fait E NA I Pass E Fail I NA X Pass E Fail E NA Xl Pass E Fail n l,A Remote Fill Piping Containment Tightness Test Result ! eass D Fait E NA E Pass E Fait E NA E Pass E Fait I NA I Pass E Fail X NA Cornmunication Test Result I eass E Fait E NA E PasS I FaiI 8 NA n pass I Fai, EI NA E Pass E Fail El NA Vent Piping Containment Tightness Test Result E pass E Fail E NA E Pass E Fair E NA n Pass E Fail E NA E Pass ! Fail EJ NA Communication Test Result ! Pass n Fail E NA E Pass E Fail X NA I eass E Fait I NA D Pass E Fait I NA Vapor Recovery Piplng Containment Tightness Test Result I Pass n Fail I NA I Pass n Fail Ex NA I eass E Fait E] NA E pass I Fait B NA Communication Test Result E Pass E Fail EI NA ! Pass E Fai, X NA I Pass n Fail E] NA E Pass I Fait I NA Turbine / Product Piping Sump Tightness Test Result E Pass I Fail n NA E Pass n Fail E NA E pass E Fait E NA fl Pass E Fail E NA Fill Riser Sump Tiohtness Test Result El Pass D Fail E NA E Pass I Fail I NA E] Pass n Fail E NA E Pass El Fail fl NA Vent / Transition Sump lD:a D d Tighlness Test Result n Pass E Fail EI NA n Pass I Fail E NA fl Pass n Fail X NA [] Pass n Fail E] NA TJDC ID:1 112 2314 3 5/6 4718 Tightness Test Result E pass E Fait E NA EJ Pass E Fail E NA X Pass E Fail E NA E Pass EX Fa,l fI NA UDC ID:5 b 7 B Tightness Test Result n pass n Fait Ex NA n Pass ! Fail EX NA n pass E Fait I NA E pass E Fait E NA IJDC ID:9 10 11 12 Tiqhtness Test Result ! Pass fl Fail I NA n Pass I Fail I NA E Pass E Fait X NA E Pass E Fail El NA AII items marked "Fail" or "N/A" must be explained in lheir respective "COMMENTS" section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the secondary containment was tested in accordance \rvith California Code of Regulations, title 23, division 3, chapter 16, section 2637 and all the information contained herein is accurate. UST Service Technician Signature -n:;7-__i _1: ._ _ _-.///2--r--*<- CERS = California trnvironmertal Reporting System,lD - Idedilication, UST: Underground storage tanlg ICC = Intemational Code Councilj NA : Nor rinli.chl.- ITDC: I Tnd.r-dirn.n..r ..rtii nfr.nt E Manufacturer Guidelinesr (Speci4/) I lndustry Code or Engineering Standard: (Spec6/,) E Engineered Method. (Specu) Atlach the testing prccedures and all documentation required to detennine the results. ICC Service T 8160834 Manufacturer Toial containment E Manufacturer Guidelines: (Spec,lr, El lndustry Code or Engineering Standard: (Speoin I Engineered Method: (Sp6o,y) Attach lhe testing procedures and all documentation required to determine the results- ICC Service Technician cert: 8160834 lnterstitial Communication Verification Method Used: lD = IrlPnfiti.afi^n UNUEKUKL'UNU S I UKA(,E I AN]\ Provide any additional comments herc. IX. REMOTE FILL PIPING CONTAINMENT Manufacturer ldentify Tank lD from section lll for each Manufacturer Atr BN cn DN Atr BN ctr Dtr I Manufactu.er Guidelines: fspec,,]1/) E lndustry Code or Engineering Standard: fspec.i&) D Engineered Method: (Specry) Atlach the testing prccedures and all documentation required to determine the results. # ofAttached Pages Remote Fill Piping Containment Testing Trainlng and Certifications (List applicable ceftifications.)Expiration Oate lnterstitial Communication Verification Method Usedi Pravide any additional comments here. (I. VENT PIPING CONTAINMENT TESTING INFORMATION Ma n ufactu re r ldentify Tank lD from section lll for each Manufacturer Atr Btr ctr DN Atr BfI ctr DN 'est Method Used:fl Manufacturer Guidelines: (Spec,fy) E lndustry Code or Engineering Standard: (Specrn E Engineered Method: (SW1W) Attach the lesting procedures and all documentation required to detemine the results,# of Attached Pages Vent Piping Containment Testing Training and Ce(ifications (l-ist appficable ceftifbations )Expiration Date lnterstitial Com.nunication Verification Method Lrsed: Prcvide any additional comments herc. Test lvlethod Used: X. COMMENTS XII. COMMENTS In = I.lcnfiff.,finn XIII. VAPOR RECOVER TAINMENT TESTING INFORMATION ira n ufactu re r ldentify Tank lD from section lll for each Manufacturer Atr Btr cfI Dtr Atr Btr ctr Dtl Test Method Used:! lvlanufacturer Guidelines; (Specify) n lndustry Code or Engineeling Standard: (Specfy) fl Engineered Method. (Specify) Arlach lhe tasling procedures and all documentation required to detemine lhe results.# of Altached Pages Vapor Recovery Piping Containment Testing Training and Cedifications (List applicable ceftifications.)Expiration Date lnterstitial Communication Verillcation Method Used: Provicle any adctional comfients here- XV. TURBINE / PRODUCT PIPING SUMP TESTING INFORMATION Manufacturer ldentify Tank lD from section Ill for each Manufaclurer Total Containment AEl BB ca Dtr AD BU cn Dtr 'est Method Used: E Manufacturer Guidelines: (Spec,ify,) I lndustry Code or Engineering Standard: (Speciy) E Engineered Methodt (Specry) Attach lhe testing procedures ancl all documentalion required to detemine lhe resul,s.,# ofAttached Pages Turlcine / Product Piping Sump Testing Training and Certifications (Lisl applicable ceftifications.)Expiration Date ICC Service Technician cert: 8160834 08t24t19 lncon Lvl 4 cert:1037433709 11t22t19 XVI. COMMENTS Ptovide any additional comments here- XIV. COMMENTS fn = Id.nrili.oii^n XVII. FILL RISER SUMP TESTING INFORMATION Menufacturer ldentify Tank lD from section lll for each Manufaclurer Total Containment Atr B8 C8 I Dtr AD Btr ctr | Dtr E Manufac{urer Guidelines: (Specrfy) E lndustry Code or Engineering Standard: (Spec,+y) I Engineered lrethod: (Specify) Atlach the testing procedures and all documenta,ion required ao detelmine the resulls.# of Attached Pages Fill Riser Sump Testing Training and Ce(ificalions (Lisl applicable ceftifications.)Expiration Date ICC Service Technician cert: 8160834 08t24t19 lncon Lvl 4 cert:1037433709 11122t19 XVIII. COMMENTS Provide any additional comfients here. XIX. VENT / TRANSITION PIPING SUMP TESTING INFORMATION Manufacturer ldentify Vent / Transition Sump lD from section lll for each Manufacturer afl I btr I cn I dtr atr I btr I c! ldtr E Manufacturer Guidelines: (Spec,ifyJ E lndustry Code or Engineering Standard: (Speofy) E Engineered Metiod: (Speon Altach the testing procedures and atl documentation rcquited to delermine the results.# of Attached Pages Vent / Transition Piping Sump Testing Training and Certifications (List applicable cedifications.)Erpiration Date XX. COMMENTS Prcvide any additional comments here. UNUtsKI'T(UUNU 5 I UKAUE IANI1 ID = Id.nriff.,ri^n Total Containment UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM lease e of 61 Manufacture(s): E Manufacturer Guidelinesi (Spec[y) I lndustry Code or Engineering Standard; (Spec/y) E Engineered Method: (Wqty) Altach lhe testing procedures and all documen,ation required to determlne the resul s. ceftifications. ) ICC Service Technician cert: 8160834 lncon Lvl 4 cert:1037433709 COMMENTS ldentify UDC lD from section Ill for each Manufacturer these pages may I lr)C = I lrl.Lr.Is.EEer .rrfairrnn rl lD = klerrifi.rli.h .i t rr:,'i: 1': )'r:u+llr'-ti.r,: l :,rit:iili',i: lti.i,il:-.t,::: , , i l - , . . t . - _ I r - l ! - f , ' - l ' _ - a 1 ! I I II li,