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

Universal Citation: 23 CA Code of Regs VII
Current through Register 2024 Notice Reg. No. 52, December 27, 2024

TYPE OF ACTION [] Installation [] Repair [] 6 Month [] 36 Month

1. FACILITY INFORMATION

CERS IDTest Date
___________________________
Facility Name
___________________________
Facility AddressCityZIP Code
___________________________

2. SERVICE TECHNICIAN INFORMATION

Company Performing the TestPhone
___________________________
Mailing Address
___________________________
Service Technician Performing Test
___________________________
Contractor/Tank Tester License Number
___________________________
ICC NumberICC Expiration Date
___________________________

3. TRAINING AND CERTIFICATIONS

Manufacturer and Test Equipment Training CertificationsExpiration Date
___________________________
___________________________
___________________________
___________________________

4. TEST PROCEDURE INFORMATION

Test Procedures UsedComponents 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 SignatureDateTotal # 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.

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