HomeMy WebLinkAboutSB989 2023 REPAIRAppendix 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
10159161 09/22/2023
Jaco #7721 Fastrip #22 (North)
4013 South H Street Bakersfield 93304
Nwestco LLC (800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Billy Lane
1073967
10281488 03/15/2025
INCON 1022163714 11/08/2024
Incon Sumps and UDC’s
Precision mechanical test gauge Tank annular’s and line secondaries
09/22/2023 4Billy Lane
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.
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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
91 STP
SMITH
0900
5.00 PSI
1000
5.00 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.
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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
UDC 15-16
GVR
33.00"
13.00"
SEE
INCON
RESULTS
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