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( i),¡ SWRCB, January 2002
Page -1 Of;S
Secondary Containment Testing Report Form
This /Orm is intended for use by contractors perj'Qrming periodic testing of UST secondary containment systems. Use the
appropriate pages of this form to report results for all components tested. The completed /orm, written test procedures, and
printouts from tests (if applicable), should be pruvided to the facility owner/operator for submittal to the local regulatory agency.
1_ FACILITY INFORMATION
Facility Name: Circle K - # 2708605
Facility Address: .
5600 Auburn Street
Facility Contact' Bakersfield, CA. 93306
DateLoca1Agency' N04341R - Re airs
Name ofLoca1 Agen P
Date of Testing:
Phone:
\
Manufacturer
Date Trainin
ires
Company Name:
Component Pass FaD Not Repain ComPonent Pass Fail Not Repairs
Tested Made Tested Made
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C ( 5 ~ ().......tc-v-( f\{)E> lÇ 0 0 !J: 0 0 0 0
Q,S~('o'\Sif ~ , - ? '6 0 O· rí 0 0 0 O'
{X')~....)eJ ~V\, 3'-~ if 0 0 .-g 0 0 0 0
0 0 0 0 0 0 0 o·
. 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
If hydrostatic testing was performed, 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 knowledge, the facts stated in this iIocument llTe lU:curate and in fuD compliance with legal requirements
Technician's Signature:
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Date:
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SWRŒ, January 2002
Page 20f5
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Test Method Developed By:
5. SECONDARY PIPE TESTING
o Piping Manufacturer . dustry Standard
o Other (Specify)
o Professional Engineer
Test Method Used:
Piping Material;
Piping Manufacturer:
Piping Diameter: _
Leng1h of Piping Run:
Product Stored:
Method and location of
i in -:-ruD isolation:
Wait time between applying
pressqre/vacuumlwater and
startin test
Test Start Time:
Initial Reading (R¡):
Test End Time:
Final Reading (R¡,):
Test Duration:
Change in Reading (RrR¡):
Pass!FaiI Threshold or
Criteria:
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o Vacuum
o Hydrostatic
Equipment Resolution:
Piping Run #
Piping Run # .
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Circle K - # 2708605
5600 Auburn Street
Bakersfield, CA. 93306
N04341 R - Repairs
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SWRŒ, January 2002
Page 3 of..3
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7.
Test Method Developed By:
UNDER-DISPENSER CONTAINMENT (UDC TESTING
D UDC Manufacturer Industry Standard D Professional Engineer
D other (Specify)
D Pressure D Vacuum )<:Hydrostatic
D Other (Specify)
Test Method Used:
UDC Manufacturer:
UDC Material:
UDC th:
Height from UDC Bottom to Top
of Hi est Pi' Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition ofUDC prior to
testin : .
Portion ofUDC Tested
Does tw'bine shut down when
UDC sensor detects liquid (both
roduct and water ?"
Turbine shutdown nse time
Is system progranuned for fail-
safe shutdown?"
Was fail-safe verified to be
operational?"
Wait time between applying
pressurelvacuumlwater and
startin test
Test Start Time:
Initial Read-
Test End Time:
Final Reading
Test Duration:
Chan e in Readin R¡):
Pass/Fail Threshold or Criteria:
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Was sensor removed for testing?
Equipment Resolution:
UDC#
UDC#
It H 1I
DYes DNo DYes DNo~ DYes DNo~ DYes DNo ?NA
DYes DNo ~NA DYes DNo )íNA DYes DNo þtNA DYes DNo 'ØNA
DYes DNo )JNA DYes DNo "NA DYes DNo ~ DYes DNo
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9'Y'es DNo DNA
J'iYes DNo DNA
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DNA F{Yes DNo DNA ~es DNo DNA
Was sensor properly replaced and
verified functional after testing?
Fes DNo DNA .,Yes DNo DNA
¥es DNo DNA
Comments - (include infonnation on repairs mack prior to testing, and recommended follow-up for failed tests)
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Circle K - # 2708605
5600 Auburn Street
Bakersfield, CA. 93306
N04341R - Repairs
J If the entire depth of the UDC is not tested, specify how much was tested. If the answer to ª=ºY of the questions indicated with an
asterisk (*) is "NO" or "NA", the entire UDC must be tested. (See SWRCB LG-160) "