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S W RCB,January 2002 Page_ _of
Secondary Containment Testing Report Form
Thisfnrm is intandedfor use by Contractors performing perlodic testing of UST secondary containment.cystams. Usa tha
appropriate pages of this form to report results for all components tested The completed form, written test procedures, and
printouts from tests rtfopplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: 10 atv U G v go -,--I Date ofTesting: / S-Of
Facility Address: C jjg -7,,4, 16 6
Facility Contact: Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector fifpresent during testing}; f' nJl P-7,E t-✓
2. TESTING CONTRACTOR INFORMATION
Company Name:RICH ENVIRONMENTAL
Technician Conducting Test:
Credentials: 3 CSLB Licensed Contractor 0 SWRCB Licensed Tank Tester
License Type. C611D40 License Number: 809850
11bnufactylgr Trainin¢
Manufacturer om onen s Date Training Expires
INCON INCON TS-STS -�
3. SUMMARY OF TEST RESULTS
Component Pass Fail Not Repairs Component Pass Fail Not Repairs
Tested Made Tested Made
/ AgAtolyWX 14 0 ❑ 0 ❑ 0 D 0
tiL Ss . et K 56 ❑ ❑ 0 ❑ ❑ ❑ u
9/ SC,(,. PIPE 0 ❑ 11 ❑ ❑ 0 0
tiL 7 Q 1 ❑ 0 0 ❑ ❑ 0
91 Q ❑ 0 0 ❑ 11 G
v0ir J-a ❑ D ❑ 0 ❑ 0 0
QQ L 3 y ❑ ❑ v ❑ ❑ ❑ ❑
❑ ❑ a 0 0 ❑ ❑ G
egle2D , u— 0 0 2 0 13 0 ❑
9C -9L El 11 0 0 0 ❑
F 4.-141 v v 0 D 0 0 0 ❑ 0
0 ❑ D 0 ❑ ❑ 0 0
If hydrostatic testing was performed,describe what was done with the water after completion of tests:
RECYCLE AND REUEjF-D,�
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best of my knowledge,the facts stated In this document are accurate and In full compGanee with legal requirements
Technician's Signature: Date: / -1S-OL
IIIIIIIIIIIIIIIIIIII 30
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S W RC B,January 2002 Page of
4. TANK ANNULAR TESTING
Test Method Developed By: 0 Tank Manufacturer Industry Standard 0 Professional Engineer
O Other(Spec)
Test Method Used: 0 Pressure I@ Vacuum D Hydrostatic
0 Other(Spect&)
Test Equipment Used; 41n. DIAL GAUGE Equipment Resolution: .5%
Sam
t
Tank# °l TankN Tank# Tank#
Is Tank Exempt From Testing?' 0 Yes )<No ❑Yes 0 No 0 Yes ❑No ❑Yes [";No
'rank Capacity: Q
Tank Material:
Tank Manufacturer:
Product Stored:
Wait time between applying
pressure/vacuum/water and
-starting test:
Test Start Time:
Initial Reading(Rr): /(,!
Test End Time: 1
Final Reading(Rj):
Test Duration: ,
Change in Reading(Rr-Ri): 0
Pass/Fail Threshold or Criteria:
Test Result: A Pass ❑Fall ❑ Pass ❑Fail 0 Pass 0 Fail 0 Pass 0 Fait
Was sensor removed for testing? Oyes ONo DNA ❑Yes ONo DNA ❑Yes ❑No DNA 0 Yes 0 No f.?NA
Was sensor properly replaced and yes ONo ONA ❑Yes ONo DNA ❑Yes 0 N 0 N ❑Yes ONo r1NA
verified functional after testin 7
Comments—(include information on repairs made prior to testing,,and recomnrendedfollow-upfbr failed tests)
r 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
SWRCB,January 2002 Page,2 of
5. SECONDARY PIPE TESTING
Test Method Developed By, 0 Piping Manufacturer :0 Industry Standard 0 Professional Engineer
0 Other(Specify)
Test Method Used: V Pressure 0 Vacuum 0 Hydrostatic
0 Other(Specify)
Test Equipment Used: 4 in. DIAL GAUGE Equipment Resolution: .5%
Piping Run# Piping Run# g/ Piping Run# Piping Run#
Piping Material:
Piping Manufacturer: S N�/ /•� t
Piping Diameter:
Length of Piping Run:
Product Stored: 0-.)L& ( *-I 9/
Method and location of
i in -run isolation: 7- N !/
Wait time between applying
pressure/vacuurn/water and
starting test:
Test Start Time: 4 j
Initial Reading(Rj: ) S
Test End Time:
Final Reading(RP): I SIft)
Test Duration: 0 ,-t,/ A,6,, 'V
Change in Reading(RP-Rr): (J s U S
Pass/Fail Threshold or n!o f ��
Criteria; `!J
Test Result: fib Pass 0 Fall Al Pass 0 Fall 0 Pass 0 Fail 0 Pass 0 Fall
Cornments—(include information on repairs made prior to testing;and reavmmendedfollow-up joijailed tesa)
SWRCB,January 2002 Page 7 of
6. PIPING SUMP TESTING
Test Method Developed By: O Sump Manufacturer 0 Industry Standard 0 Professional Engineer
D Other(S eci&
Test Method Used: 0 Pressure ❑Vacuum Z Hydrostatic
0 Other(Specify)
Test Equipment Used: INCON TS-STS Equipment Resolution:,000in.
FMM Sump# Sump# f Sump# Sump#
Sump Diameter, Z.
Sump Depth: y ,v ,v
Swnp Material: i Lift
Height from Tank Top to Top of
Highest Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition of sump prior to testing: L
Portion of Sump Tested' I �,04-u v
Does turbine shut down when
sump sensor detects liquid(both )(Yes D No 0 NA )S Yes ❑No 0 NA 0 Yes 0 No DNA 0 Yes ❑No ❑NA
roduct and water l?'
Turbine shutdown response time t &C
Is system programmed for fail-safe
shutdown?' )4 Yes 0 No O )•NA Yes 0 No DNA ❑Yes D No Q NA D Yes C No DNA
Was fai[--safe verified to be P,Yes ❑No ❑NA X Yes D No ❑NA ❑Yes 0 No DNA ❑Yes 0 No ❑NA
operational?*
Wait time between applying
pressure/vacuum/water and starting 3o,�t.•v 30,07,-Ij
test:
Test Start Time: :Sy /0'
Initial Reading(R): �yy,— q.7y
Test End Time:
Final Reading(Kr): S•1 ti 7Sy,.,� / •j la(7
Test Duration: ►,,v n„v ,v i-I
Change is Reading(RF-RO: CJ�r v oatq,-j • ,ti ./)0 ,N
Pass/Fall Threshold or Criteria: ,, au, .ez ,
Vest Result: X Pass 0 Fall .4 Pass 0 Fall ❑ Pass ❑Fill 0 Pass 0 Fail
Was sensor removed for testing? AYes D No DNA j(Yes 0 No DNA Dyes ❑No DNA 0 Yes 0 No 0 NA
Was sensor properly replaced and Yes 0 No 0 NA Yes 0 No DNA ❑Yes ❑No ON ❑Yes 0 No DNA
verified functional after testin ? _ Lx -
C010ritetltS—(include information on repairs made prior to testing and recommended Lollow-up for failed tests)
`If the entire depth of the sump is not tested,specify how much was tested. If the answer to gflY of the questions indicated with an
asterisk(•)is"NO"or"NA",the entire sump trust be tested. (See SWRCB LG-160)
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SWRCB,January 2002 Page of 7
7. UNDER-DLSPENSER CONTAINMENT TESMG
Test Method Developed By: 0 UDC Manufacturer lid industry Standard 0 Professional Engineer
❑Other(Spec6)
Test Method Used: ❑Pressure 0 Vacuum a Hydrostatic
0 Other(Specify)
Test Equipment Used: INCON TS—STS Equipment Resolution. .000l n.
UDC# - UDC# - UDC# UDC#
UDC Manufacturer. T6 I G
UDC Material:
UDC Depth-.
'✓ r-v
Height from UDC Bottom to Top
of Highest Pi pi Penetradon: /o�•ti /�
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition of UDC prior to ,v
testing: ( L61-V CLFA
Portion of UDC Tested / .v / -v
Does turbine shut down when
UDC sensor detects liquid(both Y[Yes 0 N DNA RYes ONO DNA ❑Yes 0 N 0 N 0Yes 0 N 0 N
Product and water)?*
Turbine shutdown response time
Is system programmed for fail-
safe shutdown?* g7Yes DNo ONA Xyes 0 N ❑NA 11 Yes 0 N 0 N OYes ONo DNA
Was fail-safe verified to be Yes 0 No DNA V Yes 0 No DNA ❑Yes 0 No ❑NA ❑Yes 0 No ❑NA
o crationa!?�
Wait time between applying
pressure/vacuum/water and 3D t,.� 3D I,,v
starting test
Test Start Time: / r,
Initial Readin (R j)-. .v
Test End Time: 17,
Final Readin 3 v +� a. •� y .�
Test Duration: 1:50-1+ti 14 t
Chan-se in Readin , : Ude.v 000,E 000,a
Pass/Fail Threshold or Criteria: JON.,j ,---, ,v 0,Z,-v
Test Result: :9 Pass 0 Fail Ad Pass ❑Fall 0 Pass 0 Fail 0 Pass 0 Fail
Was sensor removed for testing? Yes 0 No ❑NA cs ONo ❑NA 0 Yes 0 No 0 NA D Yes 0 No DNA
Was sensor properly replaced and
verified functional after testing? 9 Yes 0 No 0 NA XYes 0 No 0 NA 0 Yes 0 No DNA 0 Yes ❑No 0 NA
Comments—(Mclude Information on repairs made prior to testing and recommendedfollow-upj for ailed tes4y)
If the entire depth of the UDC is not tested,specify how much was tested. If the answer to aM of the questions indicated with an
asterisk(i)is"NO"or"NA",the entire UDC must be tested. (See SWRCB LG-160)
e3
SWRC8,lenuary 2002 Page CY of
8. FILL RISER CONTAINMENT SUMP TESTING
Facility is Not FAuipped With Fill Riser Containment Sumps ❑
Fill Riser Containment Sumps are Present,but were Not Tested 0
Test Method Developed By: 0 Sump Manufacturer IS Industry Standard 0 Professional Engineer
0 Other(Specify)
Test Method Used: 0 Pressure 0 Vacuum 9 Hydrostatic
❑Other(Specify)
Test Equipment Used: INCON TS—STS Equipment Resolution: .000 in.
F[ll Sume# Fill Sum # Fill Sump# Fip Sump#
Sump Diameter;
Sump Depth:
Height from Tank Top to Top of
Hi est 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
pressure/vacuum/water and /V „�•n
Starting test: 1 iJ
Test Start Time:
In tlai Reading R&
Test End Time:
Final Readin
Test Duration:
Change in Reading R R :
Pass/Fail Threshold or Criteria:
Test Result: 0 Pass 0 Fall ❑ Pass 0 Fail 0 Pass ❑Fail 0 Pass 0 Fail
Is there a sensor in the sump? 0 Yes 0 No 0 Yes 0 No 0 Yes 0 No 0 Yes 0 No
Does the sensor alarm when
either product or water is 0 Yes 0 No 0 NA D Yes 0 No ❑NA 0 Yes ❑No DNA D Yes D No O NA
detected?
Was sensor removed for testing? ❑Yes 0 No 0 NA 0 Yes 0 No DNA 0 Yes ❑No ❑NA 0 Yes 0 No DNA
Was sensor properly replaced and
verified functional after testin ? 0 Yes 0 No 0 NA 0 Yes 0 No 0 NA 0 Yes 0 No 0 NA D Yes 0 No r,NA
COnMleDts—(include inbrmatiorr on repairs made prlor to and recommended follow-upfor failed tests)
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SWRCB,January 2002 Page of
9. SPiLUOVERML CONTAINMENT BOXES
Facility7is 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 2 Industry Standard 0 Professional Engineer
0 Other(S ec6
Test Method Used: 0 Pressure 0 Vacuum SI Hydrostatic
0 Other(Spec'
Test Equipment Used: INCON TS—STS Equipment Resolution: •000in.
�) spin sox#vplL 9/ Spill Box#(AAA Spill Box# Spill Box#
Bucket Diameter:
Bucket Depth:
Wait time between applying
pressure/vacuum/water and 3O-j
startih test;
Test Start Time:
Initial Reading(RO: S,YW, 40, 2S
Test End Time:
Final Reading(RF):
Test Duration:
Change in Reading(RF-RO: ,
Pass/Fail Threshold or
Criteria;
Test Result. 9 Pass 0 Fall �'Pass 0 Fall 0 Pass 0 Fail 0 Pass 0 Fail
Comments—(include lrlfbrmatlon on repairs made prior to telling;and recommendedfol low-upf failed tests)
91STO
TEST STARTED 10:40 AM
TEST STARTED 15/12/2008
BEGIN LEVEL 610?55 AM RIO BRAVO CHEVRON
END TIME
RIO BRAVO CHEVRON EHD DATE 15/12/2008 6201 LAKE MING AVE
6201 LAKE MING AVE END LEVEL 6.1206 IN B�RSFIELD
BAKERSFIELD LEAK THRESHOLU 0.002 IN 10,2-5 Ap}
TEST RESULT PASSED
15/12/2008 1:05 PM 15/12/2006
SUMP LEAK TESS REPORT
SUMP LEAK TEST REPORT 67UPR
1-2 _.. ...- ... -.._. 10:06 AM
91STP T STARTED r 08
TEST STARTED 12:50 PM TEST STARTED 15/448.3 IN
TEST STARTED 15/12/2088 TEST STARTED 10:56 AM g�;IN LEVEL 10'21 AM
BEGIN LEVEL 3.8451 IN TEST STARTED 15/12/2008 END TIME 15/12/2008
END TIME 1:05 Ph BEGIN LEVEL 6.1206 2 IN END DATE 5.4484 IN
END DATE END LEVEL 15/12/2008
3.845400IN END TIME 11:11 AM �EfK THRESHOLD O'PASSED
LEAK THRESHOLD 0.002 IN END DATE 15/12/2006 SES-T RESULT
TEST RESULT PASSED END LEVEL 6.1200 IN
LEAK THRESHOLD 0.082 IN
TEST RESULT PASSED
3-4 _`._..,......._..
TEST STARTED 12:50 Ph
TEST STARTED 15/12/2008
BEGIN LEVEL 2.4232 IN
END TIME 1:05 PM
END DATE 15/12/2008
END LEVEL 2.4230 IN
LEAK THRESHOLD 0.002 IN RIO BRAVO CHEVRON
TEST RESULT PASSED 6201 LAKE MING AVE
RIO BRAVO CHEVRON BAKERSFIELD
6201 LAKE MING AVE
BAKERSFIELD 1y/12/2008 10:03 AM
15/12/2008 10:40 AM SUMP LEAK TEST REPORT
SUMP LEAK TEST REPORT 87UPR
87STP TEST STARTED 9:48 AM
TEST STARTED 15/12/2008
TEST STARTED 10:24 AM BEGIN LEVEL 5.4486 IN
TEST STARTED 15/12/2008 END TIME 10:03 AM
RIO BRAVO CHEVRON BEGIN LEVEL 5.7941 IN END DATE 15/12/2008
6201 LAKE MING AVE END TIME 10:39 AM END LEVEL 5.4484 IN
BAKERSFIELD END DATE 15/12/2008 LEAK THRESHOLD 0.602 IN
END LEVEL 5.7942 IN TEST RESULT PASSED
15/12/2008 1:21 PM LEAK THRESHOLD 0.002 IN
SUMP LEAK TEST REPORT TEST RESULT PASSED
1-2 91VPR
` TEST STARTED 1:06 PM TEST STARTED 9:48 AM
TEST STARTED 15/12/2008 TEST STARTED 15/12/2008
BEGIN LEVEL 3.8453 IN BEGIN LEVEL 6.9771 IN
END TIME 1:21 PM END TIME 10:03 AM
END DATE 1542/2008 END DATE 15/12/2008
END LEVEL 3.8453 IN RIO BRAVO CHEVRON END LEVEL 6.9757 IN
LEAK THRESHOLD 0.092 IN 6201 LAKE MING AVE LEAK THRESHOLD 0.002 IN
TEST RESULT PASSED BAKERSFIELD TEST RESULT PASSED
15/12/2008 10:55 AM
3-4 SUMP LEAK TEST REPORT - -
TEST STARTED 1:06 PM 911 log,
TEST STARTED 15/12/2008 87STP TEST STARTED
BEGIN LEVEL 2.4229 IN TEST STARTED 18.96 AM
END TIME 1:21 PM , TEST STARTED 10:40 AM 15/12/2068
END DATE 15/12/2008 TEST STARTED 15/12/2008 BEGIN LEVEL 6.9754 IN
BEGIN LEVEL
END LEVEL 2.4229 IN 5.7941 IN ENO TIME 10:21 RM
END TIME 10:55 AM E'ND LATE 15/
LEAK THRESHOLD 0.002 IN END DATE 15/12/2008 END LEVEL 12/2188
TEST RESULT PASSED END LEVEL 5.7943 12/2 IN BEAK THRESHOLD 6 9765 IN
LEAK THRESHOLD 0.002 IN TEST REcfU`T 8.882 IN
TEST RESULT PASSED PASSED
1
SB989 TESTING FAILURE REPORT
SITE NAME: Q/D dk�z Sc/o'yAD1J DATE:/"�
ADDRRss:(Q,?l L±&c ttj- IA�_4LAF TECHNICIAN: ay4-L-/
CITY: �FI,�c Q SIGNATURE: Z� i
SITE CONTACT:
THE FOLLOWING COMPONENTS WER$ REPLACED/REPAIRED TO COMPLETE T8E SB989
TESTING.
LIST OF PARTS REPLACED/REPAIRED:
REPAIRS:
LABOR:
PARTS INSTALLED_