Cal. Code Regs. Tit. 23, div. 3, ch. 16, app VII

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Current through Register 2024 Notice Reg. No. 43, October 25, 2024

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

Cal. Code Regs. Tit. 23, div. 3, ch. 16, app VII

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.

1. New Appendix VII filed 8-27-2018; operative 10/1/2018 (Register 2018, No. 35).