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S W RCB,January 2002 Page A—of v
Secondary Containment Testing Report Form
This form is intanded for use by contractors performing periodic testing of UST secondary containment systams. Use the
appropriate pages of this form to report results for all components tested The completed form, written test procedures, and
prinrouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency,
1. FACILITY INFORMATION
Facilit Name: Date of Testing:
Facility Address:
Facility Contact: Phone:
Date Local Agency Was Noti ed of Testing:
Name of Local Agena Inspector(ifpresent during testing):
2. TESTING CONTRACTOR INFORMATION
Company Name:RI CH ENVIRONMENTAL
Technician Conducting Tesr. &112 G'l>
Credentials: 0CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
License Type. C611D40 License Number. 809850
Manufacturer Trainine
Manufacturer Component(s) Date Training Expires
INCON INCON TS-STS -O
3. SUMMARY OF TEST RESULTS
Component Pass Fail Not Repairs Component Pass Fail Not Repairs
Tested Made Tested Made
Sd ❑ ❑ 0 0 ❑
Id ❑ D ❑ At ❑ LA
JR g�rSPECOWDARY P.P%- - x-1 ❑ o n x ❑ ❑
❑ 1 ❑ Q I ❑ ❑
9 ❑ Q 0 ® 0 ❑ 1 0
10 D
D G ❑❑ ❑Q » ❑ D 0
C1 C) 0 It 0 D ❑ D
C3 1) (3 ❑ ❑ o r
❑ a 11 ❑ Q D n
0 ❑ Q 13 0
0 0 D ❑
P2- -,
o ❑ ❑ n
If hydrostatic testing was performed,describe what was done with the water after completion of tests:
RECYCLE AND REUSED
CERTIFICATION OF TECHNTCIAN RESPONSISLE.FOR CONDUCTING THIS TESTING
To Me best of my knowled , facts stated in this document are accurate and In full compliance witlt legal requirements
Technician's Signature: Date: -6�ou.Q�
IIIIIII VIII III IIII 34
IE
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5W RCB,January 2002 Paoe—2,of 3-
4, TANK ANNULAR TESTING
Test Method Developed By: O Tank Manufacturer I Industry Standard 0 Professional.Engineer
O Other(Spec)
Test Method Used: 0 Pressure 9 Vacuum 0 Hydrostatic
O Other(Specify)
Test Equipment Used: 41n. DIAL GAUGE Equipment Resolution: .5%
Tank ggr, Tank N Tank tt 41 Tank 01
Is Tank Exempt From Testing?' 0 Yes 19 No 0 Yes lB No 0 Yes COLNo 0 Yes G No
Tank Capacity:
Tank Material:
Tank Manufacturer:
Product Stored: q
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading(R,): krq MA to me,
Test End Time:
Final Reading(R,:): lo HA
Test Duration:
Change in Reading(Rr-Rt): O,
Pass/Fail Threshold or Criteria: O. 6-0 0124 kWj
Test Result: )d Pass 0 Fall X Pass 0 Fail XPass 0 Fail 0 Pass 0 Fail
Was sensor removed for testing? 10 Yes 0 No 0 NA KYes ❑No DNA V Yes ❑No 0 NA 0 Yes D No f.;NA
Was sensor properly replaced and X Yes 0 No 0 NA Il oYes O No DNA 1AYes O No DNA 0 Yes 0 No 0 NA
verified functional after testing?
Comments—(include irformation on repairs made prior to testinkand reeommendedfollow-upfor failed tests)
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(ax6))
' 3aS�S
S WRCO,January 2002 Page of
5. SECONDARY PIPE TESTING
Test Method Developed By: 0 Piping Manufacturer 3d industry Standard 0 Professional Engineer
0 Other(Spec(fy)
Test Method Used: K Pressure 0 Vacuum 0 Hydrostatic
0 Other(Spec#y)
Test Equipment Used: 4 in. DIAL GAUGE Equipment Resolution: .5%
Piping Run Piping Run Piping Run#91 Piping Run#MIC
Piping Material:
Piping Manufacturer:
Piping Diameter: 2— 2
Length of piping Run:
Product Stored:
Method and location of
piping-run isolation;
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading(Rt): psi A
Test End Time:
Final Reading(Rr): CAI
Test Duration:
Change in Reading(RF-R4):
Pass/Fail Threshold or PIS
Criteria;
Teat Result: Pass 0 Fail 1K Pass 0 Fail Pau 0 Fail Pau 1 0 Fail
Comments—(include information on repairs made prior to testinj,and recommended follow-upfor failed tests)
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S\1'RCB,January 2002 Page of
6. PIPING SUMP TESTING
Test Method Developed By: ❑Sump Manufacturer R industry Standard D Professional Engineer
Cl tuber(Specify)
Test Method Used: 0 Pressure 0 Vacuum 81 Hydrostatic
0 Other(Specify)
Test Equipment Used: INCO TS—STS Equipment Resolution:.o o o i n.
Sump Sump# Sump# Sump#
bsk-
Swnp Diameter:
Sump Depth:
Swnp Material:
Height from Tank Top to Top of
Hig4est Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration: Z1 i0a
Condition of sump prior to testing: el g�W
Portion of Sump Tested'
Does turbine shut down when
sump sensor detects liquid(both drYes DNo DNA )OYes ONo DNA 10 Yes 0No DNA XdYes ONo DNA
product and water)?
Turbine shutdown response time Z 2-sr-
Is system programmed for fail-safe )(Yes DNo ❑NA JdYes 0No DNA aYes DNo DNA AlYes ONo DNA
shutdown?*
Was fail-safe verified to be )il Yes DNo DNA UYes 0 No ❑NA la Yes DNo. DNA X Yes 0 No 0 NA
operational?*
Wait time between applying
pressure/vacuum/water and stating
test
Test Start Time: H Iq Am 111f �}�7tj AN leni.P AM
Initial Reading(Rj): W Zrw v;.Izg .(„p3 t
Test End Time: 11110 l i ! ICIC2 (622&d
Final Reading(Rr): 9 taganj W-61ky"ba f4,c2jpj
Test Duration: HI I
Change in Reading(Rr-R,): ,
Pass/Fail Threshold or Criteria:
Test Result: Q Pass 0 Fail CL Pass • 0 Fail %Pass •0 Fall B Pass 0 Fail
Was sensor removed for testing? WYes ONo DNA NYes 0No DNA $Yes 0 N ONA 2Yes 0No DNA
Was sensor properly replaced and &Yes ❑No ❑NA SYes ❑No ❑NA N Yes ❑No DNA $Yes ONo DNA
verified functional after testirizz
Comtnen s—(include information on repairs made prior to testing and recommended fo!!ow-up for(ailed tests)
If the entire depth of the sump is not tested,specify how much was tested. If the answer to gRy of the questions indicated with an
asterisk(•) is"NO,,or"NA",the entire sump must be tested, (See SWRCB LG-160)
SWRCB,January 2002 Page of
7. UNDER-DISPENSER CONTAINMENT C TESTWG
Test Method Developed By: 0 UDC Manufacturer ®Industry Standard 0 Professional Engineer
0 Other(Specify)
Test Method Used: D Pressure D Vacuum SI Hydrostatic
❑Other(Spec)
Test Equipment Used: INCON TS—STS Equipment Resolution: -000in-
UDC#( UDC#3 UDC# UDC#
UDC Manufacturer:
UDC Material:
UDC Depth:
Height from UDC Bottom to Top Q
of Highest Piping Penetration: f
Height from UDC Bottom to
Lowest Electrical Penetration: An phi Ld
Condition of UDC prior to
testing.,
Portion of UDC Tested l ad- ALI
Does turbine shut down when
UDC sensor detects liquid(both 13 Yes KNo DNA ❑Yes XNo DNA ❑Yes $No 0 N OYes )qNo DNA
product and water)?'
Turbine shutdown response time glA
Is system programmed for fail- 0 Yes D No U NA 0 Yes 0 N CKNA 0 Yes DNo 9NA D Yes DNo )kNA
safe shutdown?
Was fail-safe verified to be
operational?*
Cl 0 No )a NA 0 Yes ❑No XNA ❑Yes 0 No JdNA 0 Yes 0 No $NA
nal
Wait time between applying
pressure/vacuum/water and
starting test Ml
Test Start Time: 04 111 ALON I
Initial Reading
Test End Time: IRK 1
Final Reading Rp):
Test Duration:
Change in Reading(RF-R,): p 0=104 0,6eeLg__Aonow
Pass/Fail Threshold or Criteria:
Test Result: Pass• 0 Fail X Pass 0 Fail 18 Pass 0 Fail 9 Pass 0 Fail
Was sensor removed for testin ? X Yes ❑No ❑NA Yes 0 N 0 NA .9 Yes 0 No ❑NA V Yes 0 No 0 NA
e as sensor properly replaced and yes ❑No ❑NA 'fit Yes O No 0 NA 'Yes ❑No ❑NA jiYes DNo O NA
verified functional after testing?
Comments--(h"elude irnjormation on r,�pairs made prior to lesung andrecommendedfollow-upforfatied tests)
If the entire depth of the UDC is not tested,specify how much was tested. If the answer to MX of the questions indicated with an
asterisk(*)is"NO"or"NA",the entire UDC must be tested. (See SWRCB LO-160)
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SWRCB,January 2002 Page (V
7. UNDER-DISPENSER CONTAINMENT UDC)TESTING
Test Method Developed By: 0 UDC Manufacturer. R Industry Standard 0 Professional Engineer
0 Other(Specify)
Test Method Used: C Pressure 0 Vacuum &Hydrostatic
n Other(Spec6)
Test Equipment Used: INCON TS—STS Equipment Resolution: .000i.n.
s
UDC# UDC# UDC# UDC#
UDC Manufacturer:
UDC Material:
UDC Depth:
Height from UDC Bottom to Top 9
of liinhest Pi in Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration: _
Condition of UDC prior to
Jesting:
Portion of UDC Tested
Does turbine shut down when
UDC sensor detects liquid(both t7 Yes X No ONA 0 Yes 0 No ❑NA 0 Yes 0 No ONA G Yes GNo 0 NA
product and water
Turbine shutdown response time _
Is system programmed for fail-
safe shutdown?' 0 Yes ❑No P(NA ❑Yes DNo DNA ❑Yes ❑No ❑NA Dyes []No ❑NA
Was fail-safe verified to be V J +—
o erational?* OYes GNo XNA OYes ONo ONA ❑Yes UNo 5NA FIYes CNo CNA
Wait time between applying
pressure/vacuum/water and M1
starting test
Test Start Time:
Initial Readin g R, :
Test End,rime: 21
Final Reading(Rr):
"Pest Duration:
Sjaqe in Readin (g RF Rt):
� ua kboluj
Pass/Fall Threshold or Criteria: 19 ONA tj _
Test Result: *Pass U Fail U Pass U Fail 0 Pass U Fail U Pass 0 Fail
Was sensor removed for testing? wl Yes ❑No ONA 0 Yes CNo DNA C Yes -_l No ONA t G Yes CNo ❑NA
Was sensor property replaced and Yes GNo DNA 0 Yes ❑No 0 NA Dyes 0 No ❑NA , U Yes D No t_NA
verified functional after testing"
Comments—(include information on repairs made prior to testing, and recommendedjo(low-up for fated tests) _
If the entire depth of the UDC is not tested,specify how much was tested. If the answer to My of the questions indicated with an
asterisk(*)is"NO"or"NA",the entire t.iDC must be tested. (See SWRCB LG-160)
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S W RCB,January 2002 Page of
S. FILL RISER CONTAiIIVMENT SUMP TESTING
Facility is Not Equipp9d With Ft11 Riser Containment Sumps 0
Fill Riser Containment Sumps are Present,but were Not Tested ❑
Test Method Developed By ❑Sump Manufacturer !&Industry Standard 0 Professional Engineer
0 Other(Speci )
Test Method Used: ❑Pressure 0 Vacuum 1)Hydrostatic
❑Other(Specify)
Test Equipment Used: INCON TS—STS Equipment Resolution: .0001n,
Fill Sum i< Fill Sum it Fill Sum q Fill Sum #
Sump Diameter.
Sump Depth:
Height from Tank Top to Top of
Highest Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to
testis :
Portion of Sump Tested
Sump Material:
Wait time between applying
pressure/vacuum/water and O�
starting test:
Test Start Time:
Initial Reading Ri):
Test End Time:
Final Reading(R F):
Test Duration:
Change in Reading R R, :
Pass/Fail Threshold or Criteria:
Test Result: ❑ Pass ❑Fail 0 Pass []Fan 0 Pass 0 Fall D Pass 0 Fall
Is there a sensor in the Sum ? 0 Yes ❑No 0 Yes D No 0 Yes 0 No 0 Yes 0 No
Does the sensor alarm when
either product or water is 0 Yes O No. ❑NA D Yes 0 No ❑NA D Yes 0 No DNA 0 Yes 0 No DNA
detected?
Was sensor removed for testis ? 11 Yes 0 No O NA 0-Yes 0 No DNA 0 Yes ❑No DNA 0 Yes ONo DNA
Was sensor property replacedand 0Yes ONo DNA ❑Yes ONo DNA 0Yes 0 N 0 N [0 Yes 0 N P.NA
verified functional after testing?
Comments—(include information on repairs made prior to testing,and recommendedfollow-Mforfatled tests)
SWRCB,January 2002 Page of
9. SPILUOVERFILL CONTAU"RNT BOXES
Facilityis Not Equipped With Spill/Overfill Containment Boxes 0
Spill/Overfill Containment Boxes are Present,but were Not Tested 0
Test Method Developed By: 0 Spill Bucket Manufacturer td industry Standard ❑Professional Engineer
❑Other(S ec )
Test Method Used: 0 Pressure ❑Vacuum a hydrostatic
0 Other(Specify)
Test Equipment Used: INCON TS—STS Equipment Resolution: .000in.
.r
Spill Bo: Spill Box Spill Box# I Spill Box#
Bucket Diameter: bj
Bucket Depth:
Wait time between applying
prossure/vacuum/water and
startin test:
Test Start Time: tMAH !(47_14M %SSM-i 14t12 A414
Initial Reading(Rt):
Test End Time: 1071 M #CLOW t 'Mae
Final Reading(RF);
Test Duration:
Change in heading(RF-R():
Pass/Fail Threshold or
Criteria:
Test Result; X Pass 0 Fail D Fail $Pass ❑Fail ❑ Pass 0 Fail
COtn merits—(include NC rmation on repairs made prior to testing, and recommended follow-up for failed tests)
. a�585
X-4 [/
1_t fP
TEST STARTED 1:24 PM
TEST STARTED 24/11/2008 TEST STARTED 1:57 Pte
BEGIN LEVEL 5,3908 IN TEST STARTED 24/11/200$
END TIME 1:39 PM BEGIN LEVEL 5.5865 IH
END DATE 24/11/200$ END TIME 2:13 PM
END LEVEL END DATE 24/11/200$
LEAK THRESHOLD 6.002 IN END LEVEL 5.5866 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT
PASSED TEST RESULT PASSED
` 1-2
TEST STARTED 1:40 PM
TEST STARTED 24/11/2008 TEST STARTED 2:13 PM
BEGIN LEVEL 5.3008 IN TEST STARTED 24/11/2008
END TIME BEGIN LEVEL 5.5866 IN
END DATE 1:55 PM END TIME 2:29 PM
24/11/2008 END DATE 24/11/2008
ENO LEVEL
LEAK THRESHOLD 563002 IN END LEVEL 5.5865 IN
TEST RESLdLT PASSED LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
5-6
TEST STARTED 9-10
TEST STARTED 24/11/26gg
IN LEVEL TEST STARTED 1:57 PP1
BEGIN TIME 2.8693 IN TEST STARTED 24/11/2008
END DATE 1:39 PM BEGIN LEVEL 3.3280 IN
24/11/2008 END TIME 2:13 PM
END LEVEL
LEAK THRESHOLD 0,.0002 IN END DATE 2 .32790IN
TEST RESULT END LEVEL 3.3279 IN
PASSED LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
S-6 9-10
TEST STARTED 1:40 PM TEST STARTED 2:1.3 PM
TEST STARTED 24/11/2008 TEST STARTED 24/11/2008
BEGIN LEVEL 2.8692 IN BEGIN LEVEL 3.3278 IN
END TIME 1:55 PM END TIME 2.29 PM
END DATE 24/11/2008 END DATE 24/11/2008
END LEVEL 2.8691 IN END LEVEL 3.3279 IN
LEAK THRESHOLD 0.002 IN LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED TEST RESULT PASSED
91UPR _ ..
DSLSTP 91STP
TEST STARTED 9:55 AM
TEST STARTED 24/11/2008 TEST STARTED 955 AM TEST STARTED 10:45 AM
BEGIN LEVEL 6.4534 IN TEST STARTED 24/11/2008
END TIME BEGIN LEVEL 5.6077 IN TEST STARTED 24/11/2008
END DATE 16:10 AM BEGIN LEVEL 4.7283 IN
END LEVEL 24/11/2008 END TIME 10:10 AM END TIME 11:01 AM
6.4526 IN END DATE 24/11/2008 END DATE 24/11/2008
LEAK THRESHOLD 0.002 IN END LEVEL 5.6064 IN END LEVEL 4.7294 IN
TEST RESULT PASSED LEAK THRESHOLD 0.002 IN LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED TEST RESIN PASSED
91VPR DSLSTP
TEST STARTED 10:12 AM TEST STARTED 10:12 AM 91STP
TEST STARTED 24/11/2008 TEST STARTED 24/11/2008
BEGIN LEVEL 6.4524 IN BEGIN LEVEL 5.6069 IN TEST STARTED 11:17 AM
END TIME 10:28 AM END TIME 10:28 AM TEST STARTED 24/11/2008
END DATE 24/11/2008 END DATE 24/11/2008 BEGIN LEVEL 4.7315 IN
END LEVEL 6.4525 IN END LEVEL 5.6086 IN END TIME 11:32 AM
LEAK THRESHOLD 0.002 IN LEAK THRESHOLD 0.002 IN END DATE 24/11/2008
TEST RESULT PASSED TEST RESULT PASSED END LEVEL 4.7315 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
B7STP
- TEST STARTED 11:17 AM
TEST STARTED 24/11/2008
89UPR BEGIN LEVEL 4.2391 IN 7-8
TEST STARTED 9:55 AM END TIME 11:32 AM
TEST STARTED 24/11/2008 END DATE 24/11/2008 TEST STARTED 1:24 PM
BEGIN LEVEL 5.4496 IN END LEVEL 4.2389 IN TEST STARTED 24/11/2008
END TIME 10:10 AM LEAK THRESHOLD 0.002 IN BEGIN LEVEL 2.7996 IN
END DATE 24/11/2008 TEST RESULT PASSED END DATE 24/11/2008 1:39 M
END LEVEL 5.4491 IN END LEVEL 2.7995 IN
TEST RESULT PASSED
LEAK THRESHOLD 0.002 ED - LEAK THRESHOLD 0.802 IN
---° ••----
TEST RESULT PASSED
87STP
TEST STARTED 11:01 AM
89UPR TEST SLEVEED 24 239208N 7-8 —� -
END TIME 11:16 AM
TEST STARTED 10:12 AM END DATE 24/11/200$ TEST STARTED 1:40 PM
TEST STARTED 24/11/200$ END LEVEL 4.2390 IN TEST STARTED 24/11/2008
BEGIN LEVEL 5.4488 IN LEAK THRESHOLD 0.802 IN BEGIN LEVEL 2.7996 IN
END TIME 10:28 AM TEST RESULT PAD 1:55 PM
END DATE 24/11/2008 END TIME
END LEVEL 5.4488 IN END DATE 24/11/2008
LEAK THRESHOLD 0.002 IN ___ _ END LEVEL 2.7995 IN
TEST RESULT PASSED LEAK THRESHOLD 0.002 IN
89STP TEST RESULT PASSED
TEST STARTED 10:45 AM
- TEST STARTED 24/11/2008
87UPR BEGIN LEVEL 4.2691 IN
END TIME 11:01 AM
TEST STARTED 9:55 AM END DATE 24/11/2008
TEST STARTED 24/11/2008 END LEVEL 4.2700 IN
BEGIN LEVEL 7,3599 IN LEAK THRESHOLD 0.002 IN
END TIME 10:10 AM TEST RESULT PASSED
END DATE 24/11/2008
END LEVEL 7.3597 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED -..
89STP
TEST STARTS 11:01 AM
87VPR
2
TEST STARTED 4/11/2008
TEST STARTED 10:12 AM BEGIN LEVEL 4 2X11116 00 IN
TEST STARTED 24/11/2008 END TIME
24/11/2008 08
BEGIN LEVEL 7.3596 IN END DATE 4.2709 IN
END TIME 10:28 AN FgD LEVEL og2 lt4
ND LEVEL 27 11/ IN TEST RESUL LD 0 �PASSED
LEAK THRESHOLD 0.002 IN
TcGT RESULT PASSED
SB989 TESTING FAILURE REPORT
SITE NAME• 4.iIEgs t4 DATE Lgw-Q%
ADDR$SS: ( TECHNICIAN:
CITY: Bar=mffem)
SIGNATURE:
SITE CONTACT: [TC(V�I
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE THE SB989
TESTING.
LIST OF PARTS REPLACED/REPAIRED:
REPAIRS:
LABOR:
PARTS INSTALLED: