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HomeMy WebLinkAboutSB989 (Retest)-3501 Mt. Vernon Ave 10-15-21Appendix 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 10155971 10-15-21 Jaco #7773 Fastrip #31 3501 Mt. Vernon Avenue Bakersfield 93306 Confidence UST Services, Inc.(800) 339-9930 2209 Zeus Court, Bakersfield, CA 93308 Justin Williams 804904 8819073 8-27-21 ICC Tech 8819073 8-27-22 Precision mechanical test gauge 91 product to eat dispensers dispenser product to west dispensers 10-15-21 3 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 91 east secondary smith 12:15 pm 5 psi 1:15 pm 5 psi 0.00” 0.00” Diesel west secondary smith 1:00 pm 5 psi 2:00 pm 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 5 of 5 9. COMMENTS