HomeMy WebLinkAboutSECONDARY CONTAINMENT TESTING FORM 10-20-08 • I IIIIIII VIII III IIII 15
IE
c
S W PCB,January 2002 Page of_
Secondary Containment Testing Report Form
This form is intendad for use by contractors performing periodic testing of UST secondary containment systems. Use the
appropriate pages of this form to report resultsfor all components tested The completed form,written test procedures. and
printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency
!. FACILITY INFORMATION
Date
Facility Name: NEV",,,
of Tessin /d-a!9 O
Facility Address: a •Jty t_v ^��' C 9
Facility Contact: Phone:
Date Local Agency Was Notifled of Testing:
Name of Local Agency Inspector(ifpresent during testing):
2. TESTING CONTRACTOR INFORMATION
Com any Name:RICH ENVIRONMENTAL
Tcchnician Conducting Test: Q�
Credentials: 3 CSLB Licensed Contractor ❑S WRCB Licensed Tank'('ester
License Type. C621D40 License Number: 809850
Manufacturer Training
Manufacturer Component(s) Date Training Expires
INCON INCON TS-STS
3. SUMMARY OF TEST RESULTS
Component Pass Fall Not I Repairs Component Pass Fall Not Repairs
ITested Made Tested Made
[] 1 ❑ 1 ❑ ,( ❑ ❑ ❑
t r7 9r D ❑ ❑ v 7- ❑ ❑ L'1
4 9 ❑ ❑ ❑ a ILL le,,P ❑ ❑ X Q
v L E . IMc ❑ ❑ ❑ PLW 9/ FiLt_ 0 ❑ 4 ❑
See. 0,&7 0 ❑ ❑ Fit- u.-, 0 ❑ D
16 . 6&c 0 D ❑ ttv t W11(Z ❑ 0 ❑
✓k y tJ2 S6C. f ❑ Q U 91 t/ 0 ❑ D
❑ ❑ D d ❑ Q f
9 r 0 0 0 0 11 ❑ 0
❑ ❑ ❑ ❑ 0 ❑ 0
D 0 ❑ 0 ❑ ❑ 1j-
0 0 ❑ 1 ❑ ❑ 0 ❑ ❑
If hydrostatic testing was perfbrmed,describe_what was done with the water after completion of tests;
RECYCLE AND RE S
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the hest of my knowledge,the facts.stated in this document are accurate and in futt compliance with legal requirements
Technician's Signature: Date: )0-0\-O-o
LE Q --
IIIIIII VIII III IIII 16
IE
SWRCB,January 2002 page a of'? ,.
4. TANK ANNULAR TESTING
'Pest Method Developed ey: 0'Dank Manu&cturer Industry Standard 0 Professional.Engineer
0 Other(Spec)
Test Method Used: 0 Pressure z Vacuum 0 Hydrostatic
❑Other(Specify)
Test Equipment Used: 4in. DIAL GAUGE Equipment Resolution: .596'
Tank# 7 Tank# g/ Tank# QS L Tank#
F:
Is Tank Exempt From Testing?' 0 Yes XNo U Yes �dNo Cl Yes ) No 0 Yes G No
Tank Capacity:
Tank Material: L- STEEL
Tank Manufacturer:
Product Stored: ow t-e,7 �t$•-+9J /fig
Wait time between applying
pressure/vacuum/water and 30 .v
startin<,test:
Test Start Time:
Initial Reading(Rr): 1f7 j 119A /
Test End Time: Jju
Final Reading(R,:): )Qzlf jam f
Test Duration:
Change in Reading(Rr-Rj):
Pass/Fail Threshold or Criteria: Q
Test Result: )d Pass ❑Fall -Z Pass ❑Fail -Z Pass ❑Fail 0 Pass 0 Fail
Was sensor removed for testing? ,ffiYes 0 N 0 N Yes 0 N 0 N j9Yes ONo DNA 0Yes 0 N. 0 N
Was sensor properly replaced and JS yes D No DNA JdYes ONo DNA AYes 0No DNA ❑Yes 0 N 0 N
verified functional after testing?
Comments—(include information on repairs made prtor to resting, and recommendedjollaw-upfor failed testa)
Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary
containment,such as systems that are hydrostatically monitored or under constant vacuum,are exempt from periodic containment
testing. (California Code of Regulations,Title 23,Section 2637(a)(6)1
SWRCR January 2002 Page of
5. SECONDARY PIPE TESTING
Test Method Developed By. 0 Piping Manufacturer :0 Industry Standard 0 Professional Engineer
0 Other(Specl&)
Test Method Used: 9 Pressure 0 Vacuum D Hydrostatic
0 Other(Specify)
Test Equipment Used: 41n. DIAL GAUGE Equipment Resolution: .5%
Piping Ran q Piping Ron g I/ Piping Run#p <, Piping Rua�
Piping Material: •7-j �-
Piping Manufacturer: t, �1L^�Ow^J .Jr✓aJ UN J v ^J
Piping Diameter: �,/. J y.� �v Si v
Length of Piping Run: 22O
Product Stored: U 2J(.k� ,° 9/ /tESEC. ( OLt vF v9♦I;Q
Method and location of
i in -run isolation: AgOT ,V fu ti aM ip AVOK,v J T e/l
Wait time between applying
pressurelvacuum/water and ��M
stanin test:
Test Start Time: p e3 r w(yt7' W U'T �✓OV`T
Initial Reading(RI):
Test End Time: P/�£$ dr[fe' r vt<E
Final Reading(Rr):
Test Duration: (>
Change in Reading(RP-Ri):
Pass/Fail Threshold or
Criteria:
Test Result: 0 Pala AFail ❑ Pass AFall 0 Pass 9Fail 0 Pass .Fail
Comments—(include information on repairs mode prior to testing, and recommended Jollaw-yp forfaded tests)
�'�'LC. S�r!� �I�� ��L FG+e. �c•%tG,rb•✓'V �TC>� /¢ /��LJ U�''+
1' ej
SWRCB,January 2002 Page ttf of
6. PIPING SUMP TESTING
Test Method Developed By: ❑Sump Manufacturer Z Industry Standard ❑Professional Engineer
❑Other(Specify)
Test Method Used: ❑Pressure ❑Vacuum YI Hydrostatic
0 Other(Spec)
Test Equipment Used: INCON T5—STS Equipment Resolution:.000in.
Sump# Y7 Sump# Sump# p L Sump q
Sump Diameter; 2 7,-,.! 27.__+
Sump Depth: ,•,! nn -✓ r1v
Smnp Material: �/ (� I uC 7 1 ��"ab
Height from Tank Top to Top of .
Highest Piping Penetration: / !'`� a�' v
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to testing: L Lg/1 v 1) c 'L1
Portion of Sump Tested'
Does turbine shut down when
sump sensor detects liquid(both )%Yes QNo 0 N ,AYes ❑No DNA <Yes 0No DNA 0Yes 0 N 0 N
product and water)?'
Turbine shutdown response time 's-Ac F Cr
Is system programmed for fail-safe Yes 0 No 0 NA ZYes ❑No DNA -4Yes ONo DNA 0Yes 0 N 0 N
shutdown?*
Was fail-safe verified to be %fires ❑No O NA )EYes 0 No ❑NA 14Yes 0 No ❑NA 0 Yes ❑No 0 NA
operational')*
Wait time between applying
pressure/vacuurn/water and starting >✓ J Q 0.1
test:
Test Start Time:
Initial Reading(Rj): �. ✓ �/, ;� 7 771.^' .y ,N
Test End Time: 6 Q: !d 1 I
Final Reading(Rr): ,t*07,a y. a
Test Duration: t5►�t�v ,,,.•✓ v r ,ti 1 �-1,U 1 + ^�
Change in Reading(Rp-R); CJm.,.1 .tea v �)0)•V 000.
Pass/Fail Threshold or Criteria: O �, ti app, ✓ .,.
Test Result: A Pass 0 Fall 9 Pass 0 Fall 9 Pass ❑Fail ❑ Pass O Fau
Was sensor removed for testing? ItLYes ❑No DNA PdYes ONo DNA JOYes ❑No DNA ❑Yes ONo DNA
Was sensor properly replaced and A Yes O No DNA 9 Yes 0 No ❑NA ,Yes 0 No ❑NA O Yes ❑No ❑NA
verified functional after testin ?
Comments—(include information an re airs made prior to testing,and recommended follow-up for foiled lesls)
'If the entire depth of the sump is not tested,specify how much was tested. If the answer to any of the questions indicated with an
asterisk(0)is"NO"or"NA",the entire sump must be tested. (See SWRCB LG-160)
aa-�Sa
S WRCB,January 2002 Page of 7
7. UNDER-DISPENSER CONTAINMENT TESTING
Test Method Developed By: 0 UDC Manufacturer 5a Industry Standard O Professional Engineer
O other(Specify)
Test Method Used: 0 Pressure 0 Vacuum 19 Hydrostatic
O Other(Sped
Test Equipment Used: INCON TS-STS EquipmentResolution: .000in.
11 in UDC# -a UDC# UDC# UDC# -
U DC Manufacturer: (Z1•i
UDC Material: $ L_ t_ f L
UDC Depth: -✓ `� 'ti
Height from UDC Bottom to Top
of Highest Piping Penetration:
Height from UDC Bottom to Q
Lowest Electrical Penetration:
Condition.of UDC prior to
testing:
Portion ofUDC Tested
Does turbine shut down when
UDC sensor detects liquid(both 0 Yes ❑No ONA ❑Yes DNo DNA ❑Yes 0 N DNA ❑Yes ❑No DNA
.product and water)?'
Turbine shutdown response time
Is system programmed for fail- 0Yes ❑No ONA OYes ONo ONA 0Yes 0 N DNA ❑Yes 0 N 13 NA
safe shutdown?
Was fail-safe verified to be 0 Yes 0 No ONA ❑Yes ❑No 0 NA 0 Yes 0 No DNA D Yes 0 No ❑NA
operational?'
Wait time between applying
pressure/vacuum/water and �O.•�1 �Q,v7� .1 3 i,i t v
startin test
Test Start Time: ..> :y7
Initial Reading(R, ... is 1 1 .•+ / -o S• v .� .^+
Test End Time: •a
Final Readin , . J• l ,
Test Duration, t ,,,,1-/ ••
v J ,Av
Change in Reading(RF-Rt): OCLZa .p a .044— 617yaA.; .00/— . 0001-0 OOO.v 001,,v
Pass/Fail Threshold or Criteria: a,,� 0 ,- A., epA.ti
Test Result: 18 Pass 0 Fail A Pass 0 Fail N'Pass 0 Fail 9 Pass 0 Fail
Was sensor removed for testing? ❑Yes ❑No ONA 0 Yes 0 No PtNA 0 Yes ❑No QNA ❑Yes ❑No ,4NA
Was sensor properly replaced and ❑Ye
verified functional after testing? s O No XNA 0 Yes 0 N JO NA O Yes O No ®NA 0 Yes 0 No R NA
Comments- include information on repairs made prior to testing,and recommendedfollow-upfor failed rests)
'if the entire depth of the UDC is not tested,specify how much was tested. If the answer to a_y of the questions indicated with an
asterisk(*)is"NO"or"NA",the entire UDC must be tested. (See SWRCB LG-160)
a3�5a-
SWRCB,January 2002 Page of 7
S. FILL RISER CONTAINMENT SUMP TESTING
Facility is Not Equipped With Fill Riser Containment Sums 0
Fill Riser Containment Sumps are Present,but were Not Tested ❑
Test Method Developed By; 0 Sump Manufacturer IS Industry Standard 0 Professional Engineer
0 Other(Specify)
Test Method Used: ❑Pressure ❑Vacuum X Hydrostatic
0 Other(Spec)
Test Equipment Used: INCON TS—STS Equipment Resolution. .000in.
Fill Sump# Fill Sum p# Fill Sume# Fill Sump#
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
testing:
Portion of Sump Tested
Sump Material:
Wait time between applying r 1
pressure/vacuum/water and (�
starting test:
Test Start Time:
Initial Reading(R,):
Test End Time:
Final Reading(R F):
Test Duration:
Change in Reading R R, :
Pass/Fail Threshold or Criteria
Test Result: ❑ Pass 0 Fail ❑ Pass 0 Fail 0 Pass 0 Fail 0 Pass D Fail
Is there a sensor in the sump? 0 Yes 0 No 0 Yes 0 No 0 Yes ❑No 0 Yes ❑No
Does the sensor alarm when
either product or water is ❑Yes ❑No DNA 0 Yes ❑No 0 NA 0 Yes ❑No DNA ❑Yes ❑No 11 NA
detected?
Was sensor removed for testing? ❑Yes ❑No DNA 0 Yes ❑No DNA ❑Yes ❑No DNA ❑Yes ❑No DNA
Was sensor properly replaced and
verified functional after testin ? Oyes 0 No ❑NA ❑Yes ❑No 0 NA ❑Yes ❑No 0 NA ❑Yes ❑No 0 NA
Comments—(include information on repairs made prior io testing and recommended follow-upforfafled tests)
aa�sa
SWRCB,January 2002 Page -7 of 7
9. SPILL/OVERFILL CONTAINMENT BOXES
Facility is Not ui ed 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 5d Industry Standard 0 Professional Engineer
0 Other(Spec)
Test Method Used: 0 Pressure 0 Vacuum Z hydrostatic
0 Other(Spec)
Test Equipment Used INCON TS-STS Equipment Resolution: .000in.
7 Spill Box NVP(L 91 Splll Box#VP Spill Box# Spill Box N
Bucket Diameter.
Bucket Depth;
Wait time between applying �� h
pressurelvacuum/waterand ^I,"J
starting test:
Test Stan Time: /O,t
Initial Reading(R,); . 7, y! v
Test End Time: r/):D / :D, lD f/
Final Reading(R}): -v Ob•7 H• ,v 41 W. v
Test Duration; ,tiI ,,n i 1/ ,•V to I
Change in Reading(RF-1Q: M).V 1,00/.'v
Pass/Fail Threshold or
Criteria: Qp .ti "10A Cba.-/
Test Result: .r4 Pass 0 Fail ,WPW 0 Fall 0 Pass 0 Fail D Pass 0 Fail
Comments-(include ii1 ormatlon on repairs made prior to testing,and recommended follow-up for jailed tests)
TES-T STARTED 1;38 PM
TEST STARTED 25,10/2006
?,ECJlN Lt 2.1029 IN
F.ND TTPIE 2:53 PPI
-ND DATE 20/10/2008 CHEVRON
END LFQEL 2.1019 IN '17525 WHITE LN
i-C-
EAK THRESHOLD 0.00-7 IN
TEST RESULT PASSED 2@/10/2008 12:58 P11
SUMP LEAK TEST REPORT
TEST STARTED 12:43 PN CHEVRON
3-4 TZS.7' STARTED 20/10/2008 2525 WHITE LN
RE610 LEVEL 5.6074 IN 11:41 AM
EST STARTED 1:5.5 PM END TIME 1258 Pti 20/io/2W
TEST STARTED 20/10/2068 END DATE 20/10/200?-
BEGIN
LE!Tl 2.1022 IN END LEVEL 5.6087 IN somP LEAK TEST REPORT
END TIME 2:10 Pt", LEAK THRESHOLD 0.002 IN
END DATE
END LEVEL 2,1020 IN TEST RESULT PASSED iaSLSTP
LEAK THRESHOLD 0.002 IN TEST STARTED 11:26 Ar,'t
fLST RESULT PASSED TEST STARTED 20/10/2008
BEGIN I-EUEL 5.6503 IN
TEST STARTED 12-'43 PM END TIME 11!41 A14
TEST STARTED 20110/200F� END DATE 20/10/2008
BEGIN LEVEL 1.4820 IN END LEVEL 5,6502 IN
END TIME I LEAK THRESHOLD 0.002 IN
2:5P, P),)
F14D ?ATE 20/10/2008 TEST RESUL-T PhSSED
END LEVEL 1.4821 IN
LEAK. THRESHOLD 0.002 IN
TEST RESULT PASSED
CHEVRON
4525 WHITE ;-N
20/10/2000 2-10 ?M
SI-IMP LEAK TEST REPORT cHE'JRON
2525 WHITE LN
1-2 20/10/2008 11:56 AM
TEST STARTED 1:55 PM
TEST STARTED 20x1012 RT
008 SUMP LEAK TEST REPO
6EC,IN LEVEL 6,6621 IN CrCVRGN
END TIME 2:13 PM DSLSTP
END DATE 2920@Fj WHITE LN
END LEVEL 6.6628 IN 1 TEST STARTED 11:41 W
LEAK THRESHOLD 1:14 PM
0.002 IN TEST STARTED 213/10/200'3
'r EST RESULT PASSED SUM' LEAK TEST RE:p,3p- BEGIN LEVEL 5.6506 4 Ali
END TIME 11-5M
END DATE 20/10/1-7008
5-6 Fi4D LEVEL 5.65E42 IN
TF'7 STARTED LEAK THRESHOLD 0-002 IN
pfi
TEST STARTED 2@/lt3/2008 TEST RESULT PASSED
BEGIN LCUEL 5,6087 J��
END TIME 1'14 PM
END DATE 20/10/200e-
END LEVEL 6089 IN
LEAK THRESHOLD 0'.002 IN
0 EVRON 7FST RESULT PASSED
'41525 WHITE LF-41
t:-,6 pti 7-8
K TEST REPORT START-ED 12.,59 pm
SUMP LEA
TEST STARTED 20-'10/2008
1,3EIiIN LEVE-1 1.4821 IN
1-2 END TIME 1:14 PM
END DATE 20/10/2008
TEST STARTED 2:11 Ptl END LFUEL 1.4837 IN
TEST STARTED 20/10/2008 LFAK THRESHOLD i-002 IN
BCGIN LEVEL. 6.6628 IN 7-"T RESULT
END TIME 2:'16 PM PASSED
END DATE 20-110/200ti,
END LEVEL 6.6628 IN
� 'EAKTHRESHOLD 0.00" IN
TEST REVALT PASS-ED
91 STP �a a15a.
7'E-ST STARTED
TEST STARTED 2010:34 A(l
BEGIN LE4j 2/1
END TIME - 46 IN
'NC DATE 10:15 qhi "7VPR
END LEVEL 20/10/Y00S
LEAK THRESHOLp 2-7740 1 TEST STARTED 9:48 AM
TEST RESULT 0.002 N TEST STARTED 20/10/2008
PASSED BEGIN LEVEL 5.0287 IN
END TIME 10:03 AM
_ END DATE 20/10/2008
END LEVEL 5.0286 IN
915TP LEAK THRESHOLD 0.002 IN
TEST STARTED TEST RESULT PAVED
TEST STARTED 20/10/2@98 10:20 AM
BEGIN LEVEL .7 39 N
END TIME 0:35 IN 41VPR
END ,DATE � 18:35 AP
END LEVEL 0/1:3r?430g TEST STARTED 9:48 AM
LEAK THRESHOLD 2.7728 IN TEST STARTED 20/18/200,F
TEST THRESHOLD 0.002 IN BEGIN LEVEL 4.0079 IN
PASSED END TIME 10:03 AM
END DATE 20/10/2008
END LE;EL 4.8593 IN
LFAK THRESHOLD 0.002 IN
TEST RESt_4LT PASSED
2525 WHITE Lh±
.. . .,.....
20:10/2 ;
10:03 Ara $7VPR
t ip)F LEA, TEST REPOT
" TES? STARTED 19:54 AM
c_,'7STP TEST STARTED 20/10/2008
BEC;IN LEVEL 5.04 IN
TEST STARTED 9:48 A1,1 END TIME 10:19 AM
TEST STARTED 20/10/208, END DATE 20/10/2008
BEGIN LEVEL 4x393 IN END LEVEL 5.927, IN
,
END TIME LEAK THRESHOLD 0.002 IN
END DATE 10:03 AM
20/10/2008 TEST RESULT PASSED
FEND LEVEL 4.6,373 IN
THRESHOLD 0.002 IN
TEST RESULT PASSED 91UPP
TEST STARTED 10:04 AM
TEST STARTED 26/10/2008
-. BEGIN LEVEL 4.3091 IN
- END TIME 10:19 AM
END DATE 20/10/2008
END LEVEL 4.6068 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED
4NEVRON
's52S WHITE L.N
10:55 AM
SUMP LEAK TEST REPOP,T
E?STP
TEST STARTED 10:40 Ahi
TEST STARTED 20/19/,�oQg
BEGIN LEVEL 4.6052 IN
END TIME 10:55 AM
END DATE 20/10/2008
END LEVEL 4.6052 IN
LEAK THRESHOLD 0.002 IN
TEST RESULT f'r1SSED
SB989 TESTING FAILURE REPORT
SITE NAME: G1 VU'J DATE: Ia'a0'O�r
ADDRESS ��� h11�'f]� L TBCmuclAN• �W�ti � Gtil
CITY: 819CA6 SIGNATURE: L="
SITE CONTACT:
THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE THE SB989
TESTING.
LIST OF PARTS REPLACED/REPAIRED:
REPAIRS:
OS L •4 D T.�.� .�yi -���J2 SSG ///leis CSC
sr f CE
LABOR:
1SL�
PARTS INSTALLED: