HomeMy WebLinkAbout2022-02-03 989
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
10123120 2/3/2022
Wash Depot Holdings, Inc.
2301 H Street Bakersfield 93301
Confidence UST Services, Inc.(800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Terrence Lay
1073967
8721725 08/10/2022
INCON 10142003709 2/7/2024
Incon Sumps and UDC’s
Precision mechanical test gauge Tank annular’s and line secondaries
2/3/2022 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
Vacuum Gauge
87 Unleaded
12,000
11:30
-15inhg
12:00pm
-15inhg
0
0
Pressure Gauge
87 Product
NOV/Smith
9:00am
5 psi
9:30am
5psi
0
0
Diesel Product
NOV/Smith
10:00am
5 psi
10:30
5 psi
0
0
91 Premium
12,000
11:30
-12inhg
12:00
-12inhg
0
0
Diesel
12,000
11:30
-17inhg
12:00
-17inhg
0
0
87 Vent
NOV/Smith
9:00am
5 psi
9:30am
5 psi
0
0
91 Product
NOV/Smith
9:00 am
5psi
9:30am
5 psi
0
0
91 Vent
NOV/Smith
9:00 am
5 psi
9:30 am
5 psi
0
0
Diesel Vent
NOV/Smith
10:00am
5 psi
10:30
5 psi
0
0
87 Vapor Return
NOV/Smith
10:30am
5 psi
10:30
5 psi
0
0
91 Vapor Return
NOV/Smith
10:30am
5 psi
10:30
5 psi
0
0
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 STP
OPW
38”
18”
11:58 am
5.3588 in
12:13 pm
5.3587 in
0.0001 in
0.002 in
UDC 3-4
Western Fiberglass
28”
15”
12:28 pm
2.3453 in
12:43 pm
2.3453 in
0in
0.002 in
91 STP
OPW
38”
16”
11:58 am
4.9295 in
12:13 pm
4.9294 in
0.0001 in
0.002 in
Diesel STP
OPW
38”
19”
2:12 pm
2.0402 in
2:28 pm
2.0399
0.0003 in
0.002 in
UDC 1/2
Western Fiberglass
28”
15”
12:28 pm
8.3526 in
12:43 pm
8.3528 in
0.0002 in
0.002 in
UDC 5-6
Western Fiberglass
28”
15”
12:28 pm
2.8044 in
12:43 pm
2.8059 in
0.0015 in
0.002 in
UDC 7-8
Western Fiberglass
28”
15”
2:45 pm
3.0719 in
3:00 pm
3.0726 in
0.0007 in
0.002 in
UDC 9-10
Western Fiberglass
28”
15”
2:45 pm
3.0693 in
3:00 pm
3.0689 in
0.0004 in
0.002 in
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 11-12
Western Fiberglass
28”
15”
1:33 pm
1.5986 in
1:48 pm
1.5989 in
0.0003 in
0.002 in
UDC 13-14
Western Fiberglass
28”
15”
1:33 pm
5.2276 in
1:48 pm
5.2281 in
0.0005 in
0.002 in
UDC 15-16
Western Fiberglass
28”
15”
1:33 pm
3.8137 in
1:48 pm
3.8139 in
0.0002 in
0.002 in
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