HomeMy WebLinkAboutMITIGATION 8/16/2004
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Secondary Containment Testing Report Form
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This form is intended for use by contractor.s perfQrming periodic testing of UST sfXondary 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 pruvided to the facility ownf:r/opf:rator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Circle K - # 2708605
Facility Address: ' 5600 Auburn Street
Facility Contact ~ Bakersfield, CA. 93306
Date Local Agency' N04341 R - Repai rs
Name of Local Agen
Facility Name:
Date of Testing:
Phone:
Company Name:
Manufacturer
Date Trainin
ires
Component Pass Fail Not Rq:¡airs Component Pass Fan Not Repairs
Tested Made Tested Made
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q ( 5 ~ (o......tc-v-( -P\-Pe g:- O 0 ß= 0 0 0 0
Q, sre...Sf/ ~ , - '2 ~ 0 0' u'rif 0 0 0 0'
!XS~M.seJ ~'" 3-~ W 0 0 it: 0 0 0 0
0 0 0 0 0 0 0 0'
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
0 0 0 0 0 0 0 0
3. SUMMARY OF TEST RESULTS
Ifhydrostatic testing was perfonned" descn'be what was done with the water after completion of tests:
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CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best ofmy krwwledge., thefacts stated in this document are accurate and infull comp1iana with legal requirements
Technician's Signature:
0'4 3-~
Date: ~ - \ {, - 0"1
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SWRCB, January 2002
Test Method Developed By:
5. SECONDARY PIPE TESTING
o Piping Manufacturer . dustry Standard
o Other (Speâfy)
o Professional Engineer
Test Method Used:
ressure
Piping Material:
Piping Manufacturer:
Piping Diameter: __
Length of Piping Run:
Product Stored:
Method and location of
i in -run isolation:
Wait time between applying
pr~vacuumlwater and
startin test
Test Start Time:
Initial Reading (Rð:
Test End Time:
Final Reading (Rp):
Test Duration:
Change in Reading (RrR¡):
Pass/Fail Threshold or
Criteria:
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o Vacuum
o Hydrostatic
Page 2 of '3
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Equipment Resolution:
Piping Run # '
If
h
Pi!Ss~!-'~b,Fill?'··;·'-i ~:,¡;·;Ð"1~~~,~iiJ·:V~[y~~~t~$·.J?~1i:~ø:j;:~&kt;
Piping Run #
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Circle K - # 2708605
5600 Auburn Street
Bakersfield, CA. 93306
N04341 R - Repairs
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SWRCB, January 2002
Page 3 of.3
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7.
Test Method Developed By:
UNDER-DISPENSER CONTAINMENT (UDC) TESTING
o UDC Manufacturer Industry Standard 0 Professional Engineer
o other (Speci}ÿ)
o Pressure 0 Vacuum ){Hydrostatic
o Other {Speci}ÿ}
Test Method Used:
UDC Manufacturer:
UDC Material:
UDC th:
Height fi:om UDC Bottom to Top
of Hi est Pi in Penetration:
Height fi:om UDC Bottomto
Lowest Electrical Penetration:
Condition ofUDe prior to
testin : '
Portion ofUDe Tested
Does turbine shut down when
UDC sensor detects liquid (both
roduct and water ?"
TuIbine shutdown nse time
Is system progranuned for fail-
safe shutdown?*
Was fail-safe verified to be
operational?*
Wait time between applying
pressurelvacuum/water and
s . test
Test Start Time:
Initial R
Test End Time:
Final Reading
Test Duration:
Chan e in Readin RV:
Pass/Fail Threshold or Criteria:
. TéStRéSÙlf:.\:·
Was sensor removed for testing?
Equipment Resolution:
UDC#
UDC#
Was sensor properly replaced and
verified functional after testing?
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DYes 9tNA DYes oNo ~ DYes oNo }tNA DYes DNo ~A
DYes DNo ~NA DYes DNo )tNA . DYes DNo ~NA DYes DNo 1ÏNA
DYes DNo ~NA DYes DNo ~NA DYes oNo ~ DYes oNo
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c¡.'Yes DNo DNA
-,ïYes ONo DNA
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DNA F(Yes DNo DNA rµ-es DNo DNA
Fes oNo DNA ~Yes DNo DNA
Yes DNo DNA
Comments - (include infonnation on repairs made prior to testing, and reCQmmendedfo/low-up for failed tests)
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Circle K - # 2708605
5600 Auburn Street
Bakersfield, CA. 93306
N04341R - Repairs
I If the entire depth of the UDC is not tested, specify how much was tested. If the answer to -ªºY of the questions indicated with an
asterisk (*) is "NO'" or "NAn. the entire UDC must be tested. (See SWRCB LG-160)