HomeMy WebLinkAboutSB989 2021
Appendix VII
Underground Storage Tank
Secondary Containment Testing Report Form
CERS = California Environmental Reporting System, ICC = International Code Council,
ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment,
Page 1 of 5
TYPE OF ACTION ܆܆ Installation ܆ Repair ܆ 6 Month ܆ 36 Month
CERS ID
Test Date
Facility Name
Facility Address
City
ZIP Code
Company Performing the Test
Phone
Mailing Address
Service Technician Performing Test
Contractor/Tank Tester License Number
ICC Number
ICC Expiration Date
Manufacturer and Test Equipment Training Certifications Expiration Date
Test Procedures Used Components Tested
I hereby certify that the secondary containment was tested in accordance with California
Code of Regulations, title 23, division 3, chapter 16, section 2637; that required supporting
documentation is attached; and all information contained herein is accurate. I understand
that test procedures shall be made available upon request by the governing authority.
Service Technician Signature Date
Total # of Pages
1. FACILITY INFORMATION
2. SERVICE TECHNICIAN INFORMATION
3. TRAINING AND CERTIFICATIONS
4. TEST PROCEDURE INFORMATION
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST
10155965 2-12-2021
Jaco #5562 Fastrip #6
1640 South Chester Avenue Bakersfield 93304
Confidence UST Services, Inc.(800) 339-9930
16250 Meacham Road, Bakersfield, CA 93314
Justin Williams
804904
8819073 8-27-22
ICC Tech 8819073 8-27-22
Incon level 4 1027843710 10-3-22
Incon 87 east stp
Precision mechanical test gauge Tank annular’s and 87 east product secondary
2-12-2021 4
Underground Storage Tank
Secondary Containment Testing Report Form
All tests marked “Fail” and any repairs made before or during the tightness test must be described in
the COMMENTS section.
Page 2 of 5
Test Method Developed by ܆܆ Manufacturer ܆܆ Industry Standard ܆܆ Professional Engineer
Test Type ܆܆ Pressure ܆܆ Vacuum ܆܆ Hydrostatic
Test Equipment Used:
Tank ID
Tank Manufacturer
Tank Capacity
Test Start Time
Initial Reading
Test End Time
Final Reading
Change in Reading
Pass/Fail Criteria
Tightness Test Results ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail
Test Method Developed by ܆܆ Manufacturer ܆܆ Industry Standard ܆܆ Professional Engineer
Test Type ܆܆ Pressure ܆܆ Vacuum ܆܆ Hydrostatic
Test Equipment Used:
Pipe Run ID
Pipe Manufacturer
Test Start Time
Initial Reading
Test End Time
Final Reading
Change in Reading
Pass/Fail Criteria
Tightness Test Results ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail
Pipe Run ID
Pipe Manufacturer
Test Start Time
Initial Reading
Test End Time
Final Reading
Change in Reading
Pass/Fail Criteria
Tightness Test Results ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail ܆܆ Pass ܆܆ Fail
Additional copies of this page may be attached.
6. TANK SECONDARY CONTAINMENT TEST
7. PIPE SECONDARY CONTAINMENT TEST
Precision mechanical test gauge
87 west
Unknown
12k gallon
9:00 am
10 hg
10:00 am
10 hg
0.00”
0.00”
Precision mechanical test gauge
87 east product
Smith
9:00 am
5 psi
10:00 am
5 psi
0.00”
0.00”
87 east
Unknown
12k gallon
9:00 am
10 hg
10:00 am
10 hg
0.00”
0.00”
91
Unknown
12k gallon
9:00 am
10 hg
10:00 am
10 hg
0.00”
0.00”
Diesel
Unknown
12k gallon
9:00 am
10 hg
10:00 am
10 hg
0.00”
0.00”
Underground Storage Tank
Secondary Containment Testing Report Form
All tests marked “Fail” and any repairs made before or during the tightness test must be described in
the COMMENTS section.
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Test Method Developed by ܆܆ Manufacturer ܆ Industry Standard ܆ Professional Engineer
Test Type ܆ Pressure ܆ Vacuum ܆ Hydrostatic
Test Equipment Used:
Sump/UDC ID
Sump Manufacturer
Sump Depth (inches)
Sump Bottom to Top of
Highest Pipe Penetration
(inches)
Test Start Time
Initial Reading
Test End Time
Final Reading
Change in Reading
Pass/Fail Criteria
Tightness Test Results ܆ Pass ܆܆ Fail ܆ Pass ܆܆ Fail ܆ Pass ܆܆ Fail ܆ Pass ܆܆ Fail
Sump/UDC ID
Sump Manufacturer
Sump Depth (inches)
Sump Bottom to Top of
Highest Pipe Penetration
(inches)
Test Start Time
Initial Reading
Test End Time
Final Reading
Change in Reading
Pass/Fail Criteria
Tightness Test Results ܆ Pass ܆܆ Fail ܆ Pass ܆܆ Fail ܆ Pass ܆܆ Fail ܆ Pass ܆܆ Fail
Additional copies of this page may be attached.
8. SUMP/UDC TEST
Incon
87 east STP
Unknown
38”
24”
10:03 am
4.260”
10:18 am
4.258”
0.002”
0.002”
Underground Storage Tank
Secondary Containment Testing Report Form
All tests marked “Fail” and any repairs made before or during the tightness test must be described in
the COMMENTS section.
Page 5 of 5
9. COMMENTS
JW 2-12-21: Repair and retest 87 east product secondary and 87 east STP. Installed new split repair test boot on 87 east
product secondary. Tested both the 87 east product secondary and STP. Both tests passed with no other repairs. Left site
with all functions normal.