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

Notes

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).

State regulations are updated quarterly; we currently have two versions available. Below is a comparison between our most recent version and the prior quarterly release. More comparison features will be added as we have more versions to compare.

No prior version found.