California Code of Regulations › Title 23 - Waters › Division 3 - State Water Resources Control Board and Regional Water Quality Control Boards › Chapter 16 - Underground Tank Regulations › Appendix VII - Underground Storage Tank Secondary Containment Testing Report Form

Current through Register 2024 Notice Reg. No. 28, July 12, 2024
TYPE OF ACTION
[]
						  Installation
[] Repair
[] 6 Month
[] 36 Month
1. FACILITY INFORMATION
CERS ID
Test Date
___________________________
Facility Name
___________________________
Facility Address
City
ZIP Code
___________________________
2. SERVICE TECHNICIAN INFORMATION
Company Performing the Test
Phone
___________________________
Mailing Address
___________________________
Service Technician Performing Test
___________________________
Contractor/Tank Tester License Number
___________________________
ICC Number
ICC Expiration Date
___________________________
3. TRAINING AND CERTIFICATIONS
Manufacturer and Test Equipment Training
						  Certifications
Expiration
						  Date
___________________________
___________________________
___________________________
___________________________
4. TEST PROCEDURE INFORMATION
Test Procedures
						  Used
Components
						  Tested
___________________________
___________________________
___________________________
___________________________
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING
				  TEST
I hereby certify that the secondary containment was
				  tested in accordance with California Code of Regulations, title 23, division 3,
				  chapter 16, section
				  2637; that required supporting
				  documentation is attached; and all information contained herein is accurate. I
				  understand that test procedures shall be made available upon request by the
				  governing authority.
Service Technician Signature
Date
Total
						  # of Pages
___________________________
CERS = California Environmental Reporting System, ICC =
				  International Code Council, ID = Identification. NA = Not Applicable, UDC =
				  Under Dispenser Containment,
6. TANK SECONDARY CONTAINMENT TEST
Test Method Developed by
[] Manufacturer
[] Industry Standard
[] Professional Engineer
Test Type
[] Pressure
[] Vacuum
[]
						  Hydrostatic
Test Equipment
						  Used:
Tank ID
Tank Manufacturer
___________________________
___________________________
___________________________
___________________________
Tank Capacity
___________________________
___________________________
___________________________
___________________________
Test Start Time
___________________________
___________________________
___________________________
___________________________
Initial Reading
___________________________
___________________________
___________________________
___________________________
Test End Time
___________________________
___________________________
___________________________
___________________________
Final Reading
___________________________
___________________________
___________________________
___________________________
Change in Reading
___________________________
___________________________
___________________________
___________________________
Pass/Fail Criteria
___________________________
___________________________
___________________________
___________________________
Tightness Test Results
[] Pass []
						  Fail
[] Pass [] Fail
[] Pass
						  [] Fail
[] Pass [] Fail
7. PIPE SECONDARY CONTAINMENT TEST
Test Method Developed by
[] Manufacturer
[] Industry Standard
[] Professional Engineer
Test Type
[]
						  Pressure
[] Vacuum
[] Hydrostatic
Test Equipment
						  Used:
Pipe Run ID
___________________________
___________________________
___________________________
___________________________
Pipe Manufacturer
___________________________
___________________________
___________________________
___________________________
Test Start Time
___________________________
___________________________
___________________________
___________________________
Initial Reading
___________________________
___________________________
___________________________
___________________________
Test End Time
___________________________
___________________________
___________________________
___________________________
Final Reading
___________________________
___________________________
___________________________
___________________________
Change in Reading
___________________________
___________________________
___________________________
___________________________
Pass/Fail Criteria
___________________________
___________________________
___________________________
___________________________
Tightness Test Results
[] Pass []
						  Fail
[] Pass [] Fail
[] Pass []
						  Fail
[] Pass [] Fail
Pipe Run ID
___________________________
___________________________
___________________________
___________________________
Pipe Manufacturer
___________________________
___________________________
___________________________
___________________________
Test Start Time
___________________________
___________________________
___________________________
___________________________
Initial Reading
___________________________
___________________________
___________________________
___________________________
Test End Time
___________________________
___________________________
___________________________
___________________________
Final Reading
___________________________
___________________________
___________________________
___________________________
Change in Reading
___________________________
___________________________
___________________________
___________________________
Pass/Fail Criteria
___________________________
___________________________
___________________________
___________________________
Tightness Test Results
[] Pass []
						  Fail
[] Pass [] Fail
[] Pass []
						  Fail
[] Pass [] Fail
8. SUMP/UDC TEST
Test Method Developed by
[] Manufacturer
[] Industry Standard
[] Professional Engineer
Test Type
[]
						  Pressure
[] Vacuum
[] Hydrostatic
Test Equipment
						  Used:
Sump/UDC ID
___________________________
___________________________
___________________________
___________________________
Sump Manufacturer
___________________________
___________________________
___________________________
___________________________
Sump Depth (inches)
___________________________
___________________________
___________________________
___________________________
Sump Bottom to Top of Highest Pipe Penetration
						  (inches)
___________________________
___________________________
___________________________
___________________________
Test Start Time
___________________________
___________________________
___________________________
___________________________
Initial Reading
___________________________
___________________________
___________________________
___________________________
Test End Time
___________________________
___________________________
___________________________
___________________________
Final Reading
___________________________
___________________________
___________________________
___________________________
Change in Reading
___________________________
___________________________
___________________________
___________________________
Pass/Fail Criteria
___________________________
___________________________
___________________________
___________________________
Tightness Test Results
[] Pass []
						  Fail
[] Pass [] Fail
[] Pass []
						  Fail
[] Pass [] Fail
Sump/UDC ID
___________________________
___________________________
___________________________
___________________________
Sump Manufacturer
___________________________
___________________________
___________________________
___________________________
Sump Depth (inches)
___________________________
___________________________
___________________________
___________________________
Sump Bottom to Top of Highest Pipe Penetration
						  (inches)
___________________________
___________________________
___________________________
___________________________
Test Start Time
___________________________
___________________________
___________________________
___________________________
Initial Reading
___________________________
___________________________
___________________________
___________________________
Test End Time
___________________________
___________________________
___________________________
___________________________
Final Reading
___________________________
___________________________
___________________________
___________________________
Change in Reading
___________________________
___________________________
___________________________
___________________________
Pass/Fail Criteria
___________________________
___________________________
___________________________
___________________________
Tightness Test Results
[] Pass []
						  Fail
[] Pass [] Fail
[] Pass []
						  Fail
[] Pass [] Fail
Sump/UDC ID
___________________________
___________________________
___________________________
___________________________
Sump Manufacturer
___________________________
___________________________
___________________________
___________________________
Sump Depth (inches)
___________________________
___________________________
___________________________
___________________________
Sump Bottom to Top of Highest Pipe Penetration
						  (inches)
___________________________
___________________________
___________________________
___________________________
Test Start Time
___________________________
___________________________
___________________________
___________________________
Initial Reading
___________________________
___________________________
___________________________
___________________________
Test End Time
___________________________
___________________________
___________________________
___________________________
Final Reading
___________________________
___________________________
___________________________
___________________________
Change in Reading
___________________________
___________________________
___________________________
___________________________
Pass/Fail Criteria
___________________________
___________________________
___________________________
___________________________
Tightness Test Results
[] Pass []
						  Fail
[] Pass [] Fail
[] Pass []
						  Fail
[] Pass [] Fail
Sump/UDC ID
___________________________
___________________________
___________________________
___________________________
Sump Manufacturer
___________________________
___________________________
___________________________
___________________________
Sump Depth (inches)
___________________________
___________________________
___________________________
___________________________
Sump Bottom to Top of Highest Pipe Penetration
						  (inches)
___________________________
___________________________
___________________________
___________________________
Test Start Time
___________________________
___________________________
___________________________
___________________________
Initial Reading
___________________________
___________________________
___________________________
___________________________
Test End Time
___________________________
___________________________
___________________________
___________________________
Final Reading
___________________________
___________________________
___________________________
___________________________
Change in Reading
___________________________
___________________________
___________________________
___________________________
Pass/Fail Criteria
___________________________
___________________________
___________________________
___________________________
Tightness Test Results
[] Pass []
						  Fail
[] Pass [] Fail
[] Pass []
						  Fail
[] Pass [] Fail
Additional copies of this page may be
				  attached.
All tests marked "Fail" and any repairs made before
				  or during the tightness test must be described in the COMMENTS
				  section.
9. COMMENTS
1. New
				  Appendix VII filed 8-27-2018; operative 10-1-2018 (Register 2018, No.
				  35).
2. Repealer and new appendix filed 8-27-2020; operative
				  10-1-2020 (Register 2020, No. 35). Filing deadline specified in Government Code
				  section
				  11349.3(a)
				  extended 60 days pursuant to Executive Order N-40-20 and an additional 60 days
				  pursuant to Executive Order N-66-20.