HomeMy WebLinkAboutFMC 2024 REPAIRSWRCB, January 2002 Page ____ of ____
Secondary Containment Testing Report Form
This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the
appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and
printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name:Date of Testing:
Facility Address:
Facility Contact:Phone:
Date Local Agency Was Notified of Testing :
Name of Local Agency Inspector (if present during testing):
2. TESTING CONTRACTOR INFORMATION
Company Name:
Technician Conducting Test:
Credentials: CSLB Licensed Contractor SWRCB Licensed Tank Tester
License Type:License Number:
Manufacturer Training
Manufacturer Component(s)Date Training Expires
3. SUMMARY OF TEST RESULTS
Component Pass Fail Not
Tested
Repairs
Made Component Pass Fail Not
Tested
Repairs
Made
If hydrostatic testing was performed, describe what was done with the water after completion of tests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements
Technician’s Signature:________________________________________________ Date:_________________________
1 2
Penske Bakersfield 09/03/2024
29296 E. Brundage Lane
Site Manager (888) 972-7581
N/A
N/A
Jones Covey Group, Inc.
Shawn Rodriguez
A, B and Haz 804431
International Code of Council Service Technician #8412602 Exp:11/19/2024
UDC 3 - 1 Hour Pressure Test
UDC 3 - 1 Hour Vacuum Test
N/A
09/03/2024
SWRCB, January 2002 Page ____ of ____
SUMP ANNULAR TESTING
Test Method Developed By: Sump Manufacturer Industry Standard Professional Engineer
Other (Specify)
Test Method Used: Pressure Vacuum Hydrostatic
Other (Specify)
Test Equipment Used: Equipment Resolution:
Sump # Sump # Sump # Sump #
Is Sump Liquid Filled?1 Yes No Yes No Yes No Yes No
Type of Liquid Used:
Sump Material:
Sump Manufacturer:
Penetration Type:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading (RI):
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF-RI):
Pass/Fail Threshold or Criteria:
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
Was sensor removed for testing? Yes No NA Yes No NA Yes No NA Yes No NA
Was sensor properly replaced and
verified functional after testing? Yes No NA Yes No NA Yes No NA Yes No NA
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
1 Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary
containment, such as systems that are hydrostatically monitored or under constant vacuum, are exempt from periodic containment
testing. {California Code of Regulations, Title 23, Section 2637(a)(6)}
2 2
Vacuum & Pressure gauges / Vacuum pump / Nitrogen Good
UDC 3 UDC 3
Propylene Glycol Propylene Glycol
Fiberglass Fiberglass
Western Fiberglass Western Fiberglass
Fiberglass Fiberglass
15 Minutes 15 Minutes
12:00pm 1:15pm
2 Psi 20 inHg
1:00pm 2:15pm
2 Psi 20 inHg
1 hour 1 hour
0 Psi 0 inHg
Pass/Fail Pass/Fail
Verified sump integrity by conducting vacuum and pressure for 1 hour each. All monitoring
fluid was reintroduced using manufacture installation instructions and verified to be at correct
levels. All testing performed today passed.