HomeMy WebLinkAboutSB989 2022
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
10125616 3/1/2022
Express Gas
928 Flower Street Bakersfield 93305
Confidence UST Services, Inc.(800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Matt Story
1073967
9118985 2/17/2023
INCON Level 4 1015653711 4/15/2023
Incon Sumps and UDC’s
Precision mechanical test gauge Tank annular’s and line secondaries
3/1/2022 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
87/91 Annular
EFS
20,216
9:30 AM
-10.0 Hg
11:30 AM
-10.0 Hg
0.00 Hg
0.00 Hg
87 Product
Smith
1:30 PM
5 PSI
2:30 PM
5 PSI
0.00 PSI
0.00 PSI
87/91 Vapor
Smith
1:30 PM
5 PSI
2:30 PM
5 PSI
0.00 PSI
0.00 PSI
87 Vent
Smith
1:30 PM
5 PSI
2:30 PM
5 PSI
0.00 PSI
0.00 PSI
91 Product
Smith
10:00 AM
5 PSI
11:00 AM
5 PSI
0.00 PSI
0.00 PSI
91 Vent
Smith
10:00 AM
5 PSI
11:00 AM
5 PSI
0.00 PSI
0.00 PSI
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
91 STP
Western Fiberglass
80.00”
30.00”
3:34 PM
1.6711”
3:49 PM
1.6721”
0.001”
0.002”
UDC 1/2
Western Fiberglass
30.0”
14.0”
1:58 PM
3.9089”
2:13 PM
3.9107”
0.0018”
0.002”
91 Fill
Western Fiberglass
77.5”
34.0”
1:05 PM
3.4419”
1:21 PM
3.4418”
0.0001”
0.002”
87 STP
Western Fiberglass
80.0”
34.0”
10:43 AM
2.2965”
10:58 AM
2.2949”
0.0016”
0.002”
87 Fill
Western Fiberglass
77.5”
34.0”
11:41 AM
5.4095”
11:56 AM
5.4091”
0.0004”
0.002”
UDC 3/4
Western Fiberglass
30.0”
14.0”
1:58 PM
3.9089”
2:13 PM
3.9107”
0.0018”
0.002”
UDC 5/6
Western Fiberglass
30.0”
14.0”
1:58 PM
2.6888”
2:13 PM
2.6892”
0.0004”
0.002”
UDC 7/8
Western Fiberglass
30.0”
14.0”
3:34 PM
5.0317”
3:49 PM
5.0308”
0.0009”
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
UDC 9/10
Western Fiberglass
30.0”
14.0”
4:01 PM
3.3822”
4:16 PM
3.3824”
0.0002”
0.002”
UDC 11/12
Western Fiberglass
30.0”
14.0”
4:22 PM
2.9344”
4:37 PM
2.9345”
0.0001”
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