HomeMy WebLinkAboutSECONDARY CONTAINMENT TESTING REPORT FORM 11-21-08 IIIIIIIIIIIIIIIIIIII 25
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Secondary Containment Testing Report Form
For Use by Unidocs Member Agencies or where approved by your Local Jurisdiction
Authority Cited: Health and Safety Code§25293; Title 23 CCR§2637(x)(4)
This form, or the standard form develped by the State Water Resources Control Board (SWRCB), must be used
by contractors performing periodic testing of underground storage tank (UST) secondary containment systems
in Unidocs member agency jurisdictions. The completed form, written test procedures, data collection logs, and
printouts from test equipment (if applicable), must be provided to the facility owner/operator for submittal to
the local regulatory agency within 30 days of the test date.
SWRCB requires that the entire volume of each sump and under-dispenser containment(UDC) system be tested
if the sump/UDC is not equipped with a continuous monitoring system that shuts down the pump when a leak is
detecetd or the leak detection sensor fails or is disconnected. [see swRCB Local Guidance Letter iG-t 60]
Systems where leak detection equipment continuously monitors both primary and secondary containment (e.g.
systems that are hydrostatically monitored or under constant vacuum) are exempt from periodic testing
requirements. [23 CCR§2637(a)(6)]
In the case of pressure/vacuum testing, My loss in pressure/vacuum during the course of the test shall be
considered a failed test, regardless of the manufacturer's criteria for declaring a passed test. [23 CCR§2637(a)(2)]
A. Facility Information
Facility Name: Costco Wholesale#688 Date of Testing:. November 21,2008
Site Address: 3800 Rosedale H
Facility Contact: Josh Beckham Phone: 661-636-0822
Date Local Agency was Notified of Testing: 11/08
Name of Local Agency Inspector(ifpresent during testing): Ernie
B. Testing Contractor Information
Company Name: W.S.K. & Sons Inc.
Credentials: ®CSLB-Licensed Contractor; ❑ SWRCB-Licensed Tank Tester
License Type: ®A;®C-10; ❑C-34;[]C-36;❑C-61 (D40) License Number: 888712
Name of Technician Conducting Tests: William S. Karras
Training by Equipment Manufacturer
Manufacturer Component(s) Date Training Expires
Phil-Tite Spill Buckets 2/09
C. Certification by Tech chin Responsible for Conducting,Testing
To the best of my knowl , fa s stated in this document are accurate and in full compliance with
legal requirements.
Technician's Signature: Date:
UN-054-1/5 www.unidomorg IIIIIIIIIIIIIIIIIIII 26 02/26/02
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Spill Bucket Testing Report Form
This form is intended for use by contractor performing annual testing of UST spill containment structures. The completed form and
printouts form tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: Costco Wholesale#688 Date of Testing: 11/21/2008
Facility Address: 3800 Rosedale Hwy., Bakersfield CA 93301
Facility Contact: Josh Beckham Phone: 661 636-0822
Date Local Agency Was Notified of Testing: Nov-08
Name of Local Ins r if resent dun testi : Ernie
2.TESTING CONTRACTOR INFORMATION
Company Name: W.S.K.&Sons Inc.
Technician Conducting Test William S.Karras
Credentials: CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester Other )
License Numbers): #888712 #5257313-UT
3.SPILL BUCKET TESTING INFORMATION
est Method Used: Hydrostatic X Vacuum Other
est Equipment Used: Visual X E ui ment Resolution:
Identify Spill Bucket(By Tank
umber Stored Product etc. 87 A 87 B 91
Bucket Installation T Contained In Sump X Contained in Sump X Contained In Sump X
Bucket Diameter. 12.0" 12.0" 12.0"
Bucket Depth: 14.25" 14.25" 14.25"
Wait time between applying
vacuum/water and start of test: 15:00 min. 16:00 min 15:00 min
est Start Time: 12:00 PM 12:00 PM 12:00 PM
Initial Reading Ri: 14.0" 14.0" 14.0"
Test End Time: 1:30 PM 1:30 PM 1:30 PM
Final Reading(RQ: 14.0" 14.0" 14.0"
Test Duration(Tf-T): 1.5 Hrs. 1.5 Hrs. 1.5 Hrs.
Change in reading(Rf-Pi): 0 0 0
Pass/Fail Threshold or
Criteria: Pass I Gross Pass 1 Gross Pass I Gross
Test Result: ass ass Pass
Comments-(Include information on repairs made prior to besting and recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONAIBLE FOR CONDUCTING THIS TESTING
I hereby cetMy that all the Information contained In this report is true,accurate,and In full compliance with legal requ irements
Technician's Signature: Waam A. �w'61 Date: 11/21/08
Spill Bucket Testing Report Form
This form is intended for use by contractor performing annual testing of UST spill containment structures. The completer/form and
printouts form tests(if applicable),should be provided to the facility owneN operator for submittal to the local regulatory agency.
1.FACILITY INFORMATION
Fadlity Name: Costco Wholesale#688 Date ofTesting: 11/21/2008
Facility address: 3800 Rosedale Hwy., Bakersfield CA 93301
Facility Contact Josh Beckham Phone:(661)636-0822
Date Local Agency Was Notified of Testing: NOV-08
Name of Local Agency Inspector fif present during testing):Erie
2.TESTING CONTRACTOR INFORMATION
Fompany Name: W.S.K.&Sons Inc.
echnician Conducting Test: William S.Karras
Credentials: CSLB Contractor X ICC Service Tech. X SWRCB Tank Tester Other(specify)
License Number(s): #888712 #5257313-UT
3.VAPOR BUCKET TESTING INFORMATION
Test Method Used: Hydrostatic X Vacuum Other
Test E Suipmnt Used: Visual Equipment Resolution:
Identify Spill Bucket(By Tank
Number, Stored Product etc. 87 A 87 B 91
Bucket Installation T lc..Ulned In Sump X Contained In Sump X Contained In Sump X
Bucket Diameter. 12.0" 12.0" 112.0"
Bucket Depth: 16.25" 16.75" 15.50"
Wait time between applying
vacuum/water and start of test: 15:00 min. 15:00 min 15:00 min.
Test Start Time: 12:00 PM 12:00 PM 12:00 PM
Initial Reading Ri: 16.0" 16.0" 15.0"
Test End Time: 1:30 PM 1:30 PM 1:30 PM
Final Reading(Rf): 16.0" 16.0" 15.0"
Test Duration(Tf-r): 1.5 Hrs. 1.5 Hrs. 1.5 Hrs.
[est hangs in reading(Rf-Ri () 0
ass/Fall Threshold or
riteria: Pass I Gross Pass I Gross Pass I Gross
Result Pass Pass Pass
Comments-(Include information on repairs made prior to testing and recommended follow-up for failed tests)
CERTIFICATION OF TECHNICIAN RESPONAIBLE FOR CONDUCTING THIS TESTING
I hereby cetfy that all the Information contained M this report Is trice,accurate,and M full compliance with legal requirements
Technician's Signature: Date: 11/21/08