HomeMy WebLinkAbout989 RESULTS 8-26-2016 From: Franzen-Hill Inc. To: 16618522171 Page:213 Date: 8/31/2010 7:16:50 AM
j 1 SWRCB,January 2002 IIIIII�IIIIIIIIIIIII 41 Page of
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Secondary Containment Testing Report Form
This form Is Intended for use by contractors perfo»ning periodic testing of UST secondary containment systems. Use the
appropriate pages of this farm to report results for all components tested. The completed form, written testprocedures, and
printouts from tests(if applicable),should he provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: ar -� Date of Testing: �
Facility Address: ,e
Facility Contact: IPhone:
Date Local Agency Was Notified of Testing
Name of Local Agency Inspector(ifpresent during testing):
2. TESTING CONTRACTOR INFORMATION
Com au Name: Franzen-Hill
Technician Conducting Test: n kew-
Credentials: B CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester
License Type:B C61/1340 A HAZ License Number: 304147
Manufacturer jEgjU1og
Manufacturer Component(s) Date Training Expires
rut
i
3. SUMMARY OF TEST RESULTS
Not Repatrs Not Repairs
Component Pass Fail Tested Made Component Pass Fall Tested Made
❑ ❑ Dk n n n n
El ❑ ❑ ❑ a ❑ 0 ❑
❑ ❑ ❑ ❑ ❑ n ❑ ❑
0 0 0 ❑ ❑ 0 ❑ ❑
0 0 ❑ 0 ❑ ❑ ❑ 0
0 a ❑ ❑ ❑ ❑ ❑ a
❑ 1 ❑ ❑ ❑ 0 1. 0 ❑ 0
❑ ❑ 0 ❑ U u ❑ n
F n a 0 1 u u
If hydrostatic testing was performed,describe what was done with the water after compietion of tests''
.................. .
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
Tb the best of my knowledge,the facts stated In this docament are accurate and In full.compllance with legal requirements
Technician's Signature: Date: ~/25
I IIIIIII VIII III IIII 42
I
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From: Franzen-Hill Inc. To: 16618522171 Page:3/3 Date: 8/31!2010 7:16:51 AM
' SWRCB,January 2002 Page ` of
7. UNDER-DISPENSER CONTAINMENT UDC TESTING
Test Method Developed By: ❑UDC Manufacturer g1ndustry Standard ❑Professionat Engineer
❑Other(Spec)
Test Method Used: ❑Pressure ❑Vacuum O�Hydrostatic
O Other(Specify)
Test Equipment Used: co&j q5 Equipment ResolutioN 447j_
UDC# UDC# UDC# UDC#
UDC Manufacturer: r g
UDC Material: s
UDC Depth:
Height from UDC Bottom to Top
of Highest Piping Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition of UDC prior to
testing: 1014
:Portion of UDC Tested is
Does turbine shut down when
UDC sensor detects liquid(both XYes ❑No DNA O Yes O No O NA O Yes ❑No ❑NA ❑Yes ❑No ❑NA
product and water)?
Turbine shutdown r nse time
Is system programmed for fail-0 yes ❑No PQ NA ❑Yes ❑No DNA ❑Yes 0 No ❑NA U Yes ❑No U NA
safe shutdown?
Was fail-safe verified to be Oyes 0 No
erational7' K NA ❑Yes ❑No ❑NA ❑Yes ❑No Q NA ❑Yes' ❑No ❑NA
o
Wait time between applying
pressure/vacuum/water andrl?,j
starting test
Test Start Time:
Initial Reading Rr :
Test End Time: 33
Final Reading(RF):
Test Duration:
Change in Reading -Rr): al
Pass/Fail Threshold or Criteria:
Was sensor removed for testing? Yes ❑No ❑NA ❑Yes ❑No O NA ❑Yes D No D NA ❑Yes O No O NA
Was sensor properly replaced and WZYes O No Fl NA ❑Yes Cl No DNA 0 Yes ❑No ❑NA ❑Yes ❑No ❑NA
verified functional after testing'?
Comments—(include information on re airs made rfor to testing, and recommended ollow-u or ailed tests
�a
' If the entire depth of the UDC is not tested,specify how much was tested. If the ariswer to My of the questions indicated with an
asterisk(*)is"NO"or"NA",the entire UDC must be tested. (See SWRC13 L0-1601
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