Page 1

UNDERGROUND STORAGE TANK

SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action

Installation Test

Repair Test

I.

Six Month Test

36 Month Test

FACILITY INFORMATION

CERS ID

Date of Secondary Containment Test

Business Name (Same as Facility Name or DBA-Doing Business As) Business Site Address

City

II.

ZIP Code

UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION

Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Contractor / Tank Tester License #

III.

Phone # ICC Certification Expiration Date

ICC Certification #

SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS

TANK ID: (By tank number, stored product, etc.)

A

B

C

T-2

D

T-3

T-4

Tank Containment Tightness Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Tightness Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Communication Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Tightness Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Communication Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Tightness Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Communication Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Tightness Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Communication Test Result

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Pass

Fail

NA

Product Piping Containment

Remote Fill Piping Containment

Vent Piping Containment

Vapor Recovery Piping Containment

Turbine / Product Piping Sump Tightness Test Result Fill Riser Sump Tightness Test Result VENT / TRANSITION SUMP ID:

a

Tightness Test Result

b

1

UDC ID: Tightness Test Result

2

5

UDC ID: Tightness Test Result

Fail

NA

9

Tightness Test Result

Fail

NA

4

7 Pass

Fail

NA

10 Pass

d

3

6 Pass

UDC ID:

c

Pass

8 Pass

Fail

NA

11 Fail

NA

Pass

12 Fail

NA

All items marked “Fail” or “NA” must be explained in their respective “COMMENTS” section.

IV.

CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING

I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature

CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = UnderDispenser Containment


UNDERGROUND STORAGE TANK

SECONDARY CONTAINMENT TESTING REPORT FORM (Page 2 of 6) V. Manufacturer

TANK SECONDARY CONTAINMENT INFORMATION Identify Tank ID from Section III for each Manufacturer

A A Test Method Used:

B B

C C

D D

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify): # of Attached Pages

Attach the testing procedures and all documentation required to determine the results. Tank Containment Testing Training and Certifications (List applicable certifications.)

VI.

Expiration Date

COMMENTS

Provide any additional comments here.

VII. Manufacturer

PRODUCT PIPING CONTAINMENT TESTING INFORMATION Identify Tank ID from Section III for each Manufacturer

A A Test Method Used:

B B

C C

D D

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify): # of Attached Pages

Attach the testing procedures and all documentation required to determine the results. Product Piping Containment Testing Training and Certifications (List applicable certifications.)

Interstitial Communication Verification Method Used:

VIII. Provide any additional comments here.

ID = Identification

COMMENTS

Expiration Date


UNDERGROUND STORAGE TANK

SECONDARY CONTAINMENT TESTING REPORT FORM (Page 3 of 6) IX.

REMOTE FILL PIPING CONTAINMENT TESTING INFORMATION

Manufacturer

Identify Tank ID from Section III for each Manufacturer

A A Test Method Used:

B B

C C

D D

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify): # of Attached Pages

Attach the testing procedures and all documentation required to determine the results. Remote Fill Piping Containment Testing Training and Certifications (List applicable certifications.)

Expiration Date

Interstitial Communication Verification Method Used:

X.

COMMENTS

Provide any additional comments here.

XI. Manufacturer

VENT PIPING CONTAINMENT TESTING INFORMATION Identify Tank ID from Section III for each Manufacturer

A A Test Method Used:

B B

C C

D D

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify):

Attach the testing procedures and all documentation required to determine the results. Vent Piping Containment Testing Training and Certifications (List applicable certifications.)

Interstitial Communication Verification Method Used:

XII. Provide any additional comments here.

ID = Identification

COMMENTS

# of Attached Pages Expiration Date


UNDERGROUND STORAGE TANK

SECONDARY CONTAINMENT TESTING REPORT FORM (Page 4 of 6) XIII.

VAPOR RECOVERY PIPING CONTAINMENT TESTING INFORMATION

Manufacturer

Identify Tank ID from Section III for each Manufacturer

A A Test Method Used:

B B

C C

D D

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify): # of Attached Pages

Attach the testing procedures and all documentation required to determine the results. Vapor Recovery Piping Containment Testing Training and Certifications (List applicable certifications.)

Expiration Date

Interstitial Communication Verification Method Used:

XIV.

COMMENTS

Provide any additional comments here.

XV. Manufacturer

TURBINE / PRODUCT PIPING SUMP TESTING INFORMATION Identify Tank ID from Section III for each Manufacturer

A A Test Method Used:

B B

C C

D D

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify):

Attach the testing procedures and all documentation required to determine the results. Turbine / Product Piping Sump Testing Training and Certifications (List applicable certifications.)

XVI. Provide any additional comments here.

ID = Identification

COMMENTS

# of Attached Pages Expiration Date


UNDERGROUND STORAGE TANK

SECONDARY CONTAINMENT TESTING REPORT FORM (Page 5 of 6) XVII. Manufacturer

FILL RISER SUMP TESTING INFORMATION Identify Tank ID from Section III for each Manufacturer

A A Test Method Used:

B B

C C

D D

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify): # of Attached Pages

Attach the testing procedures and all documentation required to determine the results. Fill Riser Sump Testing Training and Certifications (List applicable certifications.)

XVIII.

Expiration Date

COMMENTS

Provide any additional comments here.

XIX. Manufacturer

VENT / TRANSITION SUMP TESTING INFORMATION Identify Vent / Transition Sump ID from Section III for each Manufacturer

a a Test Method Used:

b b

c c

d d

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify):

Attach the testing procedures and all documentation required to determine the results. Vent / Transition Sump Testing Training and Certifications (List applicable certifications.)

XX. Provide any additional comments here.

ID = Identification

COMMENTS

# of Attached Pages Expiration Date


UNDERGROUND STORAGE TANK

SECONDARY CONTAINMENT TESTING REPORT FORM (Page 6 of 6) XXI.

UNDER-DISPENSER CONTAINMENT TESTING INFORMATION

Manufacturer(s)

Identify UDC ID from Section III for each Manufacturer

1 7 1 7 Test Method Used:

2 8 2 8

3 9 3 9

4 10 4 10

5 11 5 11

6 12 6 12

Manufacturer Guidelines (Specify): Industry Code or Engineering Standard (Specify): Engineered Method (Specify):

Attach the testing procedures and all documentation required to determine the results. UDC Testing Training and Certifications (List applicable certifications.)

XXII.

Expiration Date

COMMENTS

Provide any additional comments here.

If the facility has more components than this form accommodates, additional copies of these pages may be attached.

UDC = Under-Dispenser Containment; ID = Identification

# of Attached Pages

Profile for Los Angeles Fire Department

Secondary Containment Testing Report Form  

Secondary Containment Testing Report Form  

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