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

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

Appendix VIII - Underground Storage Tank Spill Container Testing Report Form

TYPE OF ACTION

[] Installation

[] Repair

[]12 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 each spill container was tested in accordance with California Code of Regulations, title 23, division 3, chapter 16, section 2637.1; 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, ID = Identification, ICC = International Code Council

6. SPILL CONTAINER DETAILS

Test Method Developed by	[] Manufacturer	[] Industry Standard		[] Professional Engineer
Test Type	[] Pressure	[] Vacuum		[] Hydrostatic
Tank ID
Spill Container Manufacturer:
Method of Cathodic Protection	[] Nonmetallic	[] Nonmetallic	[] Nonmetallic		[] Nonmetallic
	[] Other	[] Other	[] Other		[] Other
Is the spill container minimum capacity five gallons excluding riser volume	[] Yes	[] Yes	[] Yes		[] Yes
	[] No*	[] No*	[] No*		[] No*
Method to keep spill container empty	[] Drain	[] Drain	[] Drain		[] Drain
	[] Pump	[] Pump	[] Pump		[] Pump
	[] Other	[] Other	[] Other		[] Other
Spill Container Test Results	[] Pass	[] Pass	[] Pass		[] Pass
	[] Fail	[] Fail	[] Fail		[] Fail
Tank ID
Spill Container Manufacturer:
Method of Cathodic Protection	[] Nonmetallic	[] Nonmetallic	[] Nonmetallic		[] Nonmetallic
	[] Other	[] Other	[] Other		[] Other
Is the spill container minimum capacity five gallons excluding riser volume	[] Yes	[] Yes	[] Yes		[] Yes
	[] No*	[] No*	[] No*		[] No*
Method to keep spill container empty	[] Drain	[] Drain	[] Drain		[] Drain
	[] Pump	[] Pump	[] Pump		[] Pump
	[] Other	[] Other	[] Other		[] Other
Spill Container Test Results	[] Pass	[] Pass	[] Pass		[] Pass
	[] Fail	[] Fail	[] Fail		[] Fail

8. COMMENTS

Describe all answers marked "Other," "No," or "Fail" and each proposed remedy.

* Mark here if:

[] Spill containers do not have a minimum capacity of five gallons and require replacement.

Additional copies of this page may be attached.

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

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