HomeMy WebLinkAboutSB989 2024Appendix 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
10134247 4/9/2024
Jaco #7785 Fastrip #32
3701 Ming Ave Bakersfield 93309
Nwestco LLC (800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Aaron Perrigo
1073967
8485827 8/8/2024
Veeder Root ATG B47853 7/30/2024
FFS Incon 1010993708 4/8/2026
Incon Sumps and UDC’s
Precision mechanical test gauge Tank annular’s and line secondaries
4/9/2024 6
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
Precision mechanical test gauge
87 prod
Smith
10:00
5 psi
11:00
5 psi
0.00
0.00
DSL prod
Smith
12:00
5 psi
1:00
5 psi
0.00
0.00
87 vent
Smith
10:00
5 psi
11:00
5 psi
0.00
0.00
91 prod
Smith
10:00
5 psi
11:00
5 psi
0.00
0.00
91 vent
Smith
10:00
5 psi
11:00
5 psi
0.00
0.00
DSL vent
Smith
10:00
5 psi
11:00
5 psi
0.00
0.00
Vapor return
Smith
10:00
5 psi
11:00
5 psi
0.00
0.00
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
Unknown
66.00”
30.00”
10:19
3.0311
10:34
3.0306
0.0005
0.002
91 fill
Unknown
62.00”
12.00”
11:39
3.3024
11:54
3.3027
0.0003
0.002
91 stp
Unknown
66.00”
30.00”
14:08
4.0031
14:23
4.0023
0.0008
0.002
DSL stp
Unknown
66.00”
30.00”
12:43
4.0102
12:58
4.0096
0.0006
0.002
87 fill
Unknown
62.00”
12.00”
11:39
3.8673
11:54
3.8675
0.0002
0.002
DSL fill
Unknown
62.00”
12.00”
11:39
2.3165
11:54
2.3157
0.0018
0.002
UDC 1-2
Unknown
34.00”
12.00”
15:17
4.0855
15:33
4.0859
0.0004
0.002
UDC 3-4
Unknown
34.00”
12.00”
15:17
3.3457
15:33
3.3459
0.0002
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
Incon
UDC 5-6
Unknown
34.00”
12.00”
15:17
4.3800
15:33
4.3818
0.0018
0.002
UDC 7-8
Unknown
34.00”
12.00”
15:17
3.7369
15:33
3.7367
0.0002
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
Replaced boot 3.5x3.5a 91 vapor line STP
Replaced boot 3.5x2.4 DSL prod Disp 7-8