HomeMy WebLinkAboutSB-989 2022CERS = California Environmental Reporting System, ICC = International Code Council,
ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment,
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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
All tests marked “Fail” and any repairs made before or during the tightness test must be described in
the COMMENTS section.
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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
All tests marked “Fail” and any repairs made before or during the tightness test must be described in
the COMMENTS section.
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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