HomeMy WebLinkAboutSB989 2024 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
10155793 09-30-24
Jaco #7705 Fastrip #641
1200 Coffee Road Bakersfield 93308
Nwestco LLC (800) 339-9930
2209 Zeus Court, Bakersfield, CA 93308
Rockland Kirk
1073967
10241356 9-10-26
Incon Level 4 #1016693714 09-28-26
Incon Sumps and UDC’s
Precision mechanical test gauge Tank annular’s and line secondaries
09-30-24 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.
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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
Incon STS
UDC 3-4
Bravo
33"
10"
See Incon Print
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
Repaired and retested UDC 3-4 with inspector on site.