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
10137943 3-11-2021
Jaco #3366 Fastrip #640 (West)
8001 White Lane Bakersfield 93309
Confidence UST Services, Inc.(800) 339-9930
16250 Meacham Road, Bakersfield, CA 93314
Justin Williams
804904
8819073 8-23-22
ICC Tech 8819073 8-23-22
Incon level 4 1027843710 10-3-22
Incon Sumps and UDC’s
Precision mechanical test gauge Piping secondaries and tank annular’s
3-11-2021 5
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 main
Unknown
12k gallon
9:00 am
10 hg
10:00 am
10 hg
0.00”
0.00”
Precision mechanical test gauge
87 main product
Smith
10:00 am
5 psi
11:00 am
5 psi
0.00”
0.00”
91 product
Smith
10:00 am
5 psi
11:00 am
5 psi
0.00”
0.00”
87 siphon
Unknown
12k gallon
10:00 am
10 hg
11:00 am
10 hg
0.00”
0.00”
91
Unknown
12k gallon
11:00 am
10 hg
12:00 pm
10 hg
0.00”
0.00”
Diesel
Unknown
12k gallon
11:00 am
10 hg
12:00 pm
10 hg
0.00”
0.00”
87 main vent
Smith
10:00 am
5 psi
11:00 pm
5 psi
0.00”
0.00”
87 siphon line
Smith
12:00 pm
5 psi
1:00 pm
5 psi
0.00”
0.00”
87 siphon vent
Smith
11:00 am
5 psi
12:00 pm
5 psi
0.00”
0.00”
91 vent/ vapor
Smith
9:30 am/1:00 pm
5 psi
10:30 am/ 2:00 pm
5 psi
0.00”
0.00”
Diesel product
Smith
9:30 am
5 psi
10:30 am
5 psi
0.00”
0.00”
Diesel vent
Smith
9:30 am
5 psi
10:30 am
5 psi
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.
Page 3 of 5
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 main stp
Unknown
77”
36”
1:51 pm
5.491”
2:07 pm
5.490
0.001”
0.002
87 main fill
Unknown
72”
12”
1:51 pm
4.535”
2:07 pm
4.533”
0.002”
0.002”
87 siphon stp
Unknown
77”
38”
12:53 pm
3.844”
1:08 pm
3.844”
0.000”
0.002”
91 stp
Unknown
77”
18”
12:53 pm
3.061”
1:08 pm
3.061”
0.000”
0.002”
Diesel stp
Unknown
77”
18”
11:10 am
3.288”
11:25 am
3.290”
0.002”
0.002”
87 siphon fill
Unknown
72”
12”
12:19 pm
4.350”
12:34 pm
4.350”
0.000
0.002”
91 fill
Unknown
72”
12”
12:19 pm
3.578”
12:34 pm
3.577”
0.000”
0.002”
Diesel fill
Unknown
72”
12”
11:10 am
3.032”
11:25 am
3.033”
0.001”
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 4 of 5
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
Additional copies of this page may be attached.
8. SUMP/UDC TEST (continued)
܆ Pass ܆ Fail
Incon
UDC 1-2
Unknown
24”
12”
2:39 pm
3.390”
2:54 pm
3.390”
0.000”
0.002”
UDC 9-10
Unknown
24”
12”
1:51 pm
2.037”
2:07 pm
2.038”
0.001”
0.002”
UDC 3-4
Unknown
24”
12”
2:39 pm
4.777”
2:54 pm
2.776”
0.001”
0.002”
UDC 5-6
Unknown
24”
12”
2:39 pm
2.445”
2:54 pm
2.444”
0.001”
0.002”
UDC 7-8
Unknown
24”
12”
2:39 pm
4.416”
2:54 pm
4.414”
0.002”
0.002”
UDC 11-12
Unknown
24”
12”
1:51 pm
2.293”
2:07 pm
2.293”
0.000”
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