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HomeMy WebLinkAboutSB989 - 2022Appendix 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 10022566 09-19-2022 Mt. Vernon & Colubus ARCO AM PM 2698 Mt. Vernon Avenue Bakersfield 93306 Nwestco LLC (800) 339-9930 2209 Zeus Court, Bakersfield, CA 93308 Ronald Clark 1073967 9482314 05-04-2024 Incon level 4 11-04-2022 1014543712 Incon Sumps and UDC’s Precision mechanical test gauge Tank annular’s and line secondaries 09-19-2022 4 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 Calibrated vacuum gauges T1 87 19,703 9:10 AM 6 HG 11:10 AM 6 HG 0 0 calibrated gauges 87 product Unknown 10:00 AM 5 PSI 11:00 AM 5 PSI 0 T2 91 11,849 9:30 AM 6 HG 10:30 AM 6 HG 0 0 91 vent Unknown 10:15 AM 5 PSI 11:15 AM 5 PSI 0 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 and probes 87 FILL 67” 0” 12:08 PM 1.706” 12:23 PM 1.706” 0.000” 0.002” UDC 1-2 30” 6” 1:32 PM 1.501” 1:47 PM 1.502” 0.001” 0.002” 91 FILL 67” 0” 11:48 AM 5.578” 12:03 PM 5.577” 0.001” 0.002” 87 STP 60” 24” 1:13 PM 3.846” 1:28 PM 3.847” 0.001” 0.002” 91 STP 60” 24” 12:54 PM 3.799” 1,:09 PM 3.801” 0.002” 0.002” UDC 3-4 30 “ 6” 1:32 PM 2.187” 1:47 PM 2.187” 0.000” 0.002” UDC 5-6 30” 6” 1:50 PM 2.135” 2:05 PM 2.134” 0.001” 0.002” UDC 7-8 30” 6” 1:50 PM 1.678” 2:05 PM 1.677” 0.001” 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