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
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.