HomeMy WebLinkAbout2021 SB989
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 X 36 Month
CERS ID
10132183
Test Date
7/16/2021
Facility Name
Gasko Food Mart
Facility Address
430 East California Ave
City
Bakersfield
ZIP Code
93306
Company Performing the Test
Advanced Compliance
Phone
6617064321
Mailing Address
4007 Brae Burn Dr Bakersfield Ca 93306
Service Technician Performing Test
Bradley Hinsley
Contractor/Tank Tester License Number
971259
ICC Number
8373948
ICC Expiration Date
8/10/2021
Manufacturer and Test Equipment Training Certifications Expiration Date
ICC Service Techican 8/10/2021
INCON STS 10/9/2021
Test Procedures Used Components Tested
PEI/RP1200-19 Sect. 4. Tank Annular
PEI/RP1200-19 Sect. 5. Line Secondary
PEI/RP1200-19 Sect. 6. Containment Sump
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
7/16/2021
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
6. TANK SECONDARY CONTAINMENT TEST
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 X Professional Engineer
Test Type ☐ Pressure X Vacuum ☐ Hydrostatic
Test Equipment Used: Annular testing setup
Tank ID 87 91
Tank Manufacturer Unknown Unknown
Tank Capacity 20,149 10,152
Test Start Time 08:45 09:15
Initial Reading -10.00 InHg -10.00 InHg
Test End Time 10:45 10:15
Final Reading -10.00 InHg -10.00 InHg
Change in Reading 0.00 InHg 0.00 InHg
Pass/Fail Criteria +/- 0.0 InHg +/- 0.0 InHg
Tightness Test Results X Pass ☐ Fail X Pass ☐ Fail ☐ Pass ☐ Fail ☐ Pass ☐ Fail
Test Method Developed by ☐ Manufacturer ☐ Industry Standard X Professional Engineer
Test Type X Pressure ☐ Vacuum ☐ Hydrostatic
Test Equipment Used: Piping secondary Testing Setup
Pipe Run ID 87 Product 91 Product Vent Vapor Return
Pipe Manufacturer Unknown Unknown Unknown Unknown
Test Start Time 08:15 08:40 09:10 11:45
Initial Reading 5.0 PSI 5.0 PSI 5.0 PSI 5.0 PSI
Test End Time 09:15 09:40 10:10 12:45
Final Reading 5.0 PSI 5.0 PSI 5.0 PSI 5.0 PSI
Change in Reading 0.0 PSI 0.0 PSI 0.0 PSI 0.0 PSI
Pass/Fail Criteria +/- 0.0 PSI +/- 0.0 PSI +/- 0.0 PSI +/- 0.0 PSI
Tightness Test Results X Pass ☐ Fail X Pass ☐ Fail X Pass ☐ Fail X 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.
7. PIPE SECONDARY CONTAINMENT TEST
8. SUMP/UDC TEST
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 X Professional Engineer
Test Type ☐ Pressure ☐ Vacuum X Hydrostatic
Test Equipment Used: INCON STS
Sump/UDC ID 87 STP 91 STP 87 Fill Sump 91 Fill Sump
Sump Manufacturer Unknown Unknown Unknown Unknown
Sump Depth (inches) 46 46 47 47
Sump Bottom to Top of
Highest Pipe Penetration
(inches)
23 35 15 34
Test Start Time 12:09 11:20 09:52 09:52
Initial Reading 4.3736 4.5910 3.1738 4.1555
Test End Time 12:24 11:35 10:07 10:07
Final Reading 4.3725 4.5905 3.1730 4.1551
Change in Reading 0.0011 0.0005 0.0008 0.0004
Pass/Fail Criteria +/- 0.0020 +/- 0.0020 +/- 0.0020 +/- 0.0020
Tightness Test Results X Pass ☐ Fail X Pass ☐ Fail X Pass ☐ Fail X Pass ☐ Fail
Sump/UDC ID UDC 1/2 UDC 3/4 UDC 5/6 Vent Pan
Sump Manufacturer Unknown Unknown Unknown Unknown
Sump Depth (inches) 35 35 35 25
Sump Bottom to Top of
Highest Pipe Penetration
(inches)
20 18 20 10
Test Start Time 10:43 10:43 12:27 12:49
Initial Reading 7.2871 6.7294 6.9968 5.9009
Test End Time 10:58 10:58 12:42 13:04
Final Reading 7.2863 6.7287 6.9968 5.9004
Change in Reading 0.0008 0.0007 0.0000 0.0005
Pass/Fail Criteria +/- 0.0020 +/- 0.0020 +/- 0.0020 +/- 0.0020
Tightness Test Results X Pass ☐ Fail X Pass ☐ Fail X Pass ☐ Fail X Pass ☐ Fail
Additional copies of this page may be attached.
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 X Professional Engineer
Test Type ☐ Pressure ☐ Vacuum X 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 (continued)
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
All Passed
9. COMMENTS