HomeMy WebLinkAboutSB-989 2019CERS = 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
Business Name (Same as Facility Name or DBA-Doing Business As)
Business Site Address
City
ZIP Code
II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.)
Phone # ( ) - Ext.
Contractor/Tank Tester License #
ICC Certification #
ICC Certification Expiration Date
III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS
Tank ID: (By tank number, stored product, etc.) A 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
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.
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