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SWRCB,January 2002 lE Page j_of
Secondary Containment Testing Report Form
This form is intendedfor use by contractors performingperiodic testing of UST secondmy containment systems. Use the
appropriate pages of this form to report results for all components tested. The completed form;written test procedures, and
printouts from tests( ..applicable),should beprovided to.the facility.owner/operator for submittal to thelocal regulatory agency.
1. :FACILITY INFORMATION
Facifi .Name: SAM'S'LIQUOR Date of Testing; 10440
Facility.Address: 801 E.CALIFORNIA AVE,BAKERSFIELD,CA
Facility Contact: SAM Phone:.
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector(if present during testingJ: ERNIE MEDINA
2. TESTING,CONTRACTOR INFORMATION
Company Name: Rich Environmental
Technician Conducting.Test: BRANDON MASON '
:Credentials: X CSLB Licensed Contractor 0 SWRCB Licensed.Tank Tester
License Type: C6l/D40 A HAZ I License Number: 3298493702
Manufacturer Trailing
Manufacturer Com onent s Date Training Expires
INCON TS-STS 7-7-12
3. SUMMARY OF TEST:RESULTS
Component Pas Not Repairs, 'Not ,Repairs
Pus Fail Component Passsil
Tested Made Tested Made '
UNL87'ANNULAR X ❑ ❑ ❑ UDC 7-8 X ❑ ❑ ❑
PREM91 ANNULAR X p ❑ ❑ 87 FILL BOX ❑ ❑ X ❑
DIESEL ANNULAR X ❑ q ❑ 87 VPR BOX X ❑ ❑
UNL87 SECONDARY X p ❑ ❑ 91 FILL BOX p ❑ X ❑
PREM91 SECONDARY X p p 91 VPR BOX X p ❑ ❑
DIESEL SECONDARY X p ❑ .❑ DIESEL FILL BOX ❑ ❑ X ❑
UNL87 STP X ❑ ❑. ❑ ❑ a ❑ ❑
PREM9.1 STP x o ❑ ❑ ❑ ❑ o ❑
DIESEL,STP X ❑ ❑ ❑ D. ❑ ❑ ❑
UDC 1-2 X E)z 0 0 ❑ ❑; ❑ ❑
UDC 3-4 X ❑ ❑ ❑ ❑ ❑ ❑ ❑.
UDC 5-6 X ❑ ❑ p ❑ ❑ 0 ❑
If.hydrostatic testing was performed,descn'be what was done with the Water after completion of tests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE.FOR CONDUCTING THIS TESTING
To the.best of my knowledge,the faces stated In this document are accurate and In full compliance with:legal requirements
Te6nioian's Signattze:,..' Date:
IIIIIIIillllllllilii 14
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SWRGB,January 2002 page 7• of 11
4. TANK ANNULAR TESTING
Test Method Developed By: p Tank:Masufacturer ❑Industry Standard ❑Professional Engineer
11 Other(Specify)
Test Method Used: ❑Pressure 0 Vacuum. 0 Hydrostatic
D'O ..CSPeC�Y)
6Testquipment Used: Equipment Resolution:
Tank#87 Tank#91 Tank#DIESEL Tank#
Is Tank ExemptFrom.Testing? ❑Yes. X No O Yes X No ❑Yes X.No. 0 Yes ❑No
Tank Capacity: UNKNOWN UKNOWN UNKNOWN
Tank Material: STEEL STEEL STEEL
Tank Manufacturer: UNKNOWN UNKNOWN UNKNOWN
Product Stored: GASOLINE GASOLINE DIESEL
Wait time between applying
pressure/vacuum/water and 10MINS 30MINS 30MINS 30MIN5
stattitt test:
Test Start Time: 9;30A 9:30A 9:30A
Initial Reading(Ril: l OHG 1 OHG IOHG
Test End Time: 10:30A 10.30A 10:30
Final'Reading(RF): 1OHG 1014G 10HG
Test Duration: 60 MINS 60 MINS 60 MINS 60MINS
Change in Reading(RF-1Q: OHG OHG OHG
Pass/Fail.Tbreshold or Criteria: 0"HG 0"HG 0";HG 0
j Was sensorremoved,for,testing? X Yes D.No ❑NA. X Yes 0 No ❑NA X Yes ❑No ❑NA C1 Yes, ❑No ❑NA
Was sensor properly replaced and X Yes ❑No ❑i3A X Yes D No DNA: X Yes ❑No O NA Yes CJ 1+10 DNA
verified functional after testin ?
COW Menft—(include information on repairs made prior to testing,and recommended follow-up for 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(a)(6))
SWRCB,January 2002 Page: '3 of 7
5. SECONDARY PIPE TESTING
Test Method Developed By: 0.Piping Manufacturer 0 Industry Standard 11 Professional Engineer
0 Other(Specify).
Test Method Used: 0 Pressure; 0 Vacuum 13 Hydrostatic
0 Other(Specify)
Test Equipment Used: Equipment Resolution:
Piping Run#87 Piping Run#f91 Piping:Run#D SL Piping Run#
Piping Material: FIBERGLASS FIBERGLASS FIBERGLASS
Piping Manufacturer: UNKNOWN UKNOWN UNKNOWN
Piping Diameter: 31N 31N 3IN
Length of Piping Run: 7OFT 65FT 60FT
Product Stored: GASOLINE GASOLINE DIESEL
Method and location of BOOT]N SUMP BOOT IN=SUMP BOOT IN SUMP BOOT IN SUMP
piping-misolatiom:
Wail time between applying-
pressure/vscuum/water and 30 MINS 39 MINS 30 MINS. 30 MINS
starting test
Test StartTime: I0:30A 10:30A 10:30A
Initial Reading(Rj): 5PSI 5PSI' 5PSI
Test EndTime: I.1:30A 1.1:3,0A. 11,:30A
Final Reading(k): 5PSI 5PSI 5PSI
Test Duration: 60 MINS 60 MINS 60 MINS 60 MINS
Change in Reading(RF-RO: OPSI OPSI. OPSI
Pass/Fail Threshold.or 0--PSI 0 PSI 0 PSI 0 PSI
Criteria:
Comments—(include information on repairs made,prior'to testing and recomme»dedf ollow-up for failed tests)
SWRCB,.January 2002 Page of
6. PIPING SUW TESTING
Test Method Developed By: 0 Sump Manufacturer 0 Industry,Standard ❑Professional Engineer
❑Qther.(Spec)
Test Method Use& p Pressure 0 Vacuum ❑Hydrostatic
Q Other(Specify)
Test Equipment Used: Equipment Resolution:
Sump#87 Sump.#91 Sump#DSL Sump#
Sump Diameter: 36IN 36IN 361N
Sump.Depth: 4314v 43IN 43IN
Sump Material: FIBERGLASS FIBERGLASS FIBERGLASS
Height from Tank.Top to Top of 20IN 18IN 221N
Hijkst P' Penetration;
Height from Tank Top to Lowest 16IN 12QI 15II+I
Electrical-Penetration:
Condition of sump prior to testing; CLEAN CLEAN CLEAN
Portion of Sump Tested` 221N 20IN 24IN
Does turbine shut down when
sump sensor:detects�liquid(both X Yes 0.No DNA X Yes D No ❑NA X Yes D No D NA ❑Yes ❑No DNA
product and water)9
Turbine,shutdown response time 5SEC 5SEC 5SEC
Is system programmed for fail-safe X Yes ❑No ❑NA X Yes ❑No ❑NA X Yes DNo DNA D.Yes ❑No .D NA
shutdown?
Was fail-safe verified to be X Yes, D No ❑NA X Yes ONO D NA X Yes ONO ❑.NA Q Yes ❑No DNA
0 oral?
Wait time between applying
pressure!vacuum/water aad,starting 30 MINS. 30 MINS 30 MINS 30 NIINS
.test:
Test Start:Time: 11:47A 12:04P 11:47A 11:04P 11:47A 12:04P
Initial Reading(n:
5387 5.386 4.449 4.449 4.463 4.463
Test End Time: 12:02P 12:14P 12:02P 12d9P 12:02P 12:19P
Final Reading(RF): 5.387: 5385 4.449 4.448 4.463 4.462
Test Duration: 15MINS 15MMS ' 15MINS 15MINS 15MINS .15MINS 15MINS 15MINS
,Change in Reading(RF-Ril: .000 0.001 .004 .001 .000 .001
Pass/Fail Threshold or Criteria .002IN .MIN .0021N MIN .MIN .002IN .9021N .002IN
i
Was sensor removed for testing? XYes: 0 N �!NA ,.XYes DNo DNA XYes' 0No DNA. dYes ❑No DNA
Was sensor properly replaced:and. X Yes D No DNA X Yes D No DNA XYes D No ❑NA. D Yes D No DNA.
verified functional after testis ?
Comments (include.information on repairs made prior to testing.ond-reeommended follow-up for failed tests)
`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(*),is"NO"or"NA",the entire sump must be test4 .(See SWRCB LG=160)
SWRCB,January 2002_ Page b of
7. UNnER-DISPENSER CONTADUdENT TESTING
Test Method Developed By: 0 UDC Manufacturer D Industry Standard 0 Professional Engineer
D odw,(Spoil)
Test Method Used`. D Pressure D vacuum 0 Hydrostatic
0 Other(Specify)
Te4 Equi . ent Used. Equipment Resolution:
UDC#1-2 UDC.#3-4 , UDC 454 UDC#7-8
UDC Manufacturer: UNKNOWN UNKNOWN; UNKNOWN UNKNOWN
UDC Material: FIBERGLASS FIBERGLASS FIBERGLASS FIBERGLASS
UDC 321N 321N 321N 32IN
Height from UDC Bottom to Top 12IN 121N LOIN 91N
of Highest Piping.Penetration:
'Height from UDC Bottom to 61N 61N 61N 6IN
Lowest Electrical.Penetration:
Condition of UDC prior to CLEAN CLEAN CLEAN CLEAN
testinx
Portion of UDC Tested 141N 14IN 121N I I IN
Does turbine shut down when
UDC sensor detects liquid(both X,Yes ❑No ❑NA X Yes ❑No DNA X Yes l7No DNA. X Yes D No DNA
uct and water f
Turbine shutdown responsetime SSEG 5SEC 5SEC 5SEC
Is system programmed for fat?
X Yes 0 N ❑NA X Yes ❑No ❑NA X Yes Q No ❑NA X Yes ❑No ❑NA
safe shutdown?*
Was fa afe verified to be
o X Yes D'No ❑NA X Yes O No 13 NA X Yes O No .❑NA X Yes DNo 11 NA
'on or al?`
Wait time between applying
pressure/vacuum/water and 30MINS 30MINS 30MINS 30MINS
starting test
Test'Start:Tnne 1:03P 1:21P LO 1:21P 158P 2:14P 1;;58P' 2:14P
Initial 5272:. 5272 5:804 5105 3.600' 3:600 3;:570. 3.:750
Test,End Time: 1:18.P_ 1:36P 1:18P 1,:36P 2:13P 2:29P 2:13P 2:29P
Final Readin (RF): 5.272 5272 5105 5.806 3.600 3.600 3.750 3.750
Test Duration: 15NUNS 15MINS OWNS' 15MINS 15MINS 15MINS' 15M1NS 15MINS
Change in.R'eadin 000 .000 001 .001 .000 0.000 .000 ".0�021N
Pass/Fail T?ireshold:or Criteria: .002IN .002IN .0021N. .002IN .0021N .0021N 002IN
Was sensor removed for testing? X.Yes O No b NA X Yes DNo DNA X Yes .DNo O Mk X Yes O No ❑NA.
Was sensor Iro1eTly replaced and
verified-functional after testing? X;Yes Q No . g NA X Yes ❑No ❑NA X Yes ❑No. 0 NAj X Yes ❑No D.NA
Comments—futclrrde inforrngtion onrepairs made prior to testirig,,arld recommended follow-up for failed 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 k('')is"NO"or"NA",:the,entire.UDC trust lie tested. (See SWRCB LG 460)
t))S43 LI
SWRCB,January 2002 Page of
S. FILL.RLSER CONTAIlVMENT-SUMP!TESTING
Facility is-Not With Fill Riser Containment Sumps 0
Fill Riser Containment Sumps are:Presmt,but were_Not, ested
Test Method Developed By: 0 Sump Manu%cti= ❑Industry Standard 0 Professional Engineer
D Other(Specify).
Test Method Used: 0 Pressure D Vacuum 0 Hydrostatic
0 Other(Sped)
Test Equipment Used: Equipment Resoluti on:
Fill Sum .# Fill Sump# Fill Sum .# Fill Sum #
�Sump Diameter.
SuW 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 Swmp Tested
,Sump Material:
Wait time between applying
pressure/vacuum/water and 30MINS 30MINS 30MINS 30MINS
test:
Test Start Time:
Initial Rm&
ing }:
Test End Time:
Final Reading
Test Duration: lSMINS 15MMS. 15MINS 15MINS: 15MINS 15MINS LUWNS 15NIINS
Change in Reading
• .0021N .0021N` 0021N 0021N .002IN
Pass/Fail:Threshold or Criteria: :002IN .002IN
Ls there a sensor in the`sump? O;Yes 0 No 0 Yes O No 0 Yes ❑No 0 Yes 0 No
Does the sensor alarm when
either product or water is O Yes 0 No DNA 0 Yes O No DNA Q Yes 0 No D NA 0 Yes 0 N O NA
detected?
Was sensor removed for testing? 0 Yes D No DNA D Yes ONo DNA 0 Yes O No ❑NA O Yes, O.No DNA
[Was sensor properly replaced and ❑Yes ❑No DNA O Yes .O No. DNA D Yes, 0 No DNA D Yes O No O NA
verified functional after testis ?
Comments—(include it}formation.on riTdrs made prior to:testing, and recommended fol low-up for failed tests)
NO FILL SLTW S AT THIS SITE.
:n)vA-5 L
SWRCB,January 2002 Page }e� of
9. SPRUOVERFILL CONTAINMENT BOXES.
Facility is RiotEquipped With S' ilUOverfiRContainment.Boxes ❑
;Spill/Overfill Containment Boxes are Present,'but were Not Tested. 0
Test Method Developed By: O Spiill.BucketManufacturer ❑Industry Standard ❑-Pmfessionaf Engine,6r
0.Other(specify)
Test Method Used: ❑Pressure ❑Vacuum D,Hydrostatic
0 Other(Sped)
Test Equipment Used: Equipment Resolution:
Spill Box#87VPR Spill Box#91VPR Spill Box# Spill Box#
Bucket Diameter: 121N 121N
Bucket Depth: 161N 1,61N
Wait time between applying
pressure/vacuum/water and 30MIN& 30MINS 30MINS. 30MINS
startin test
Test Start Time: 9:58A 10:18A 9:58A 10:18A
Initial Reading.(Pq): 7.053 T054 5.761 5.761
Test End Time: 10:13A, 10:33A 10:13A 10:33A
final Reading(Rr): 7.054 7:054 5:761 5.761.
Test Duration: 15MINS. 15MINS 15MINS IWNS 15MINS 15MNS 15MINS 15MINS
Change in:Reading(Rp-Rf): .00i .000 .000 .000
Pass/Fail Threshold or .0021N .002IN ..0021N .0021N .002IN .002IN! .0021N .0021N
Criteria:
Comments--(include information,on repairs made prior to testing and recommendedfollow-up for failed tests)
.- -~.87))PR
- ----__ ---- __'- -.
91STP 3-4 ` �
. ^~. STARTED v
TEST STARTED. 10/08e2810
TEST STARTED 11:47 AM TEST STARTED
TEST STARTED 1 END TIME Aili,3 AM'
BEGIN LEVEL 4.4499 1 H BEGIIN. LEVEL S.WS�JN, END DATE 10/08/2010
END TIME 12,02 PM END DATE 0�W8/�W10 � LEAK THRESHOLD 0.002 IN
END LEVEL 4. 'END LEVEL 5.8056 IN 'TESTRESVLT PASSED
LEAK THRESHOLD 0.002-In LEAK THRESHOLD 0.1802 IN
TEST RESULT PASSED TEST RESULT pfG£ED
'-__' ---
91STp 87VPR
TEST '
TEST STARTED -'
BEGIN LEVEL 7 0542 IN
END TIME BEGIN LEVEL 12;19 PM END TIME 10'33 AIM
END DATE 10/08/2010 END TIME 1 .36 PM END DATE lViB$/2010
END LEVEL 4.4484 IN END END LEVEL 7.1543 IN
LEAK THRESHOLD 0.082 Im LEAK THRESHOLD 0.002 IN
/Eu/ RESULT PASSED LEAK THRESHOLD, 0.002 IN TEST RESULT PASSED
TEST RESULT PASSED
5�6 . ---`'-------- ------�---'--
DSLSTP 910PR .
TES`
. TEST STARTED 9:58 AM BEGIN LEVEL 5.
TEST STARTED 10/ffi/20lig BEGIRLEUEL 3:.6008 1 TEST STARTED
�-- E�� TIME 7616 IN
END LEVL '^463 1, 1 N LEAK - '-
LEAK o~ ' TE3f ~^ 57614"
TEST RESULT PASSED .Ea/ RESULT ponmcD
�
-------' -- ' --^ ' 5-6
91WPR
'--' -
TEST STARTED 2114 PM ' TEST
TEST STARTED 12:04 PM TEST STARTED 10/08/2010 TEST sTAkTED 1VOS/2010
' B[GI LEVtL 5.7614 IN
uc*/n LEVEL 4.4630 IN END TIME 2.29 PM END TIME 10-133 AM
_- - E _ END LEVEL 5.7615 IN
'END LEVEL 4.4628- IN tFrAK THRESHOLD 0.002 IN LEAK THRESHOLD O.M IN
' END DATE 10/08/2010
.ENDDATE is/8"10 END LEVEL 3.660 IN LEAK THRESHOLD 0..802 IN `ES' Rc"*L' ' '~~^-
S� ' TEST RESULT PASSED
RESULT PAWED
' -' ------------------ 7-8
TEST STARTED 1;58, PM
TEST STARTED 1:03 PM TEST STARTED 1 0/08/-2010
TEST STARTED 10/08/2010:: EpiN LML 3.75" IN
ENDTIME 1:118" END DATE 10/0.8/2010
END DATE 10/08/2018
END LEVEL 3.�Saq :IN
END LEUEL 5-.2724 IN�-�
'
LEAK 0.002
LEAK TESTR[S�LT� PASSED
TEST RESULT. rA,"E"
' ---- ------ ------�~ --' 7�8
1-2
I-EST STARTED 1 �M TEST -STARTED TEST STARTED l0v/@V2910
TES
13EGIN LEUEL �.2726 IN END TIME- 2.'29..PM
END TIME 1:36 PM END DATE 10/08/2010
END DATE la/W2819
END LEVEL 3.7,509 IN
ODLEVEL 5.2727 IN
LEAK 0610.02 IN
ALBAKI TEST RESULT PASSED
"~,. ~^~~^. PASSED� �
^
' |
�
"
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SB989 TESTING FAILURE REPORT
STlE NAME: SAMS LIOUOR DATE: 10-8-10.
ADDRESS: 801 E.CALIFORNIA AVE TECHNICIAN: BRANDON MASON
CITY: BAKERSFIELD SIGNATURE:
THE FOLLOWING COMPONENTS WERE REPLACEDIREPAIRED TO COMPLETE
TESTING.
REPAIRS: NONE
LABOR: NONE
PARTS INTALLED• NONE
i
NAME; TITLE:
SIGNATURE:
THE ABOVE NAMED PERSON TAKES FULL.RESPONSIBILITY OF NOTIFYING
THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR
ANY NEEDED RETESTING.THIS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROM NON-COMPLIANCE.
A COPY OF THIS DOCUMENT HAS BEEN LEFT ON-SITE FOR YOUR
CONVIENENCE.