2023 0519 - Loma Linda VA Hospital SB989..pdf
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- Solicitation number
- 36C26226Q0125
About this file
This is Appendix VII, an Underground Storage Tank Secondary Containment Testing Report Form used by California to document compliance testing of secondary containment systems for underground storage tanks.
The form documents a 36-month inspection conducted on May 19, 2023, at Jerry Pettis Memorial Veterans Hospital in Loma Linda, California (CERS ID 10040881). Western Pump, Inc. performed the testing, with service technician Agustin Garcia (License #673853, ICC #8032748 expiring 8/19/2024) conducting the work. The technician held Franklin Fueling Level IV certification expiring 2/23/2025. Testing included three XERXES tanks (T1, T2, T3) each with 20,000-gallon capacity and secondary containment sump systems with depths ranging from 66 to 74 inches. Tank secondary containment was tested using vacuum method with a 4" diameter glycerin-filled vacuum gauge. All three tanks passed testing with zero change in readings and zero pass/fail criteria threshold. Piping secondary containment included six piping runs (T1 Supply, T1 Return, T2 Supply, T2 Return, T3 Supply, T3 Return) manufactured by Smith, tested using pressure method with 0-15 PSI glycerin-filled pressure gauge. All piping passed with zero change in readings. Sump/UDC testing used INCON TS-STS Sump Tester equipment on three fill sumps (T1, T2, T3), all manufactured by XERXES and all passing hydrostatic testing with minimal changes in readings (+0.0001 to +0.0004 inches) within acceptable criteria of +/-0.002 inches. Supporting documentation including test photographs was attached per California Code of Regulations Title 23, Division 3, Chapter 16, Section 2637. The report was signed February 1, 2022, with four total pages.
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Other files
| File | Type | Posted |
|---|---|---|
| 2025 0513 - Loma Linda VA Hospital AMC.pdf | ||
| 2024 0520 - Loma Linda VA Hospital OPE..pdf | ||
| 36C26226Q0125_1.docx | DOCX document |
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Text version
CERS = California Environmental Reporting System, ICC = International Code Council, ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, TYPE OF ACTION Installation Repair 6 Month 36 Month
CERS ID
Test Date
Facility Name
Facility Address
City
ZIP Code
Company Performing the Test
Phone
Mailing Address
Service Technician Performing Test
Contractor/Tank Tester License Number
ICC Number
ICC Expiration Date
Manufacturer and Test Equipment Training Certifications Expiration Date
Test Procedures Used Components Tested
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
1. FACILITY INFORMATION
2. SERVICE TECHNICIAN INFORMATION
3. TRAINING AND CERTIFICATIONS
4. TEST PROCEDURE INFORMATION
5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST
(619) 239-9988
All tests the COMMENTS section.
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
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
Additional copies of this page may be attached.
6. TANK SECONDARY CONTAINMENT TEST
7. PIPE SECONDARY CONTAINMENT 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
Additional copies of this page may be attached.
8. SUMP/UDC TEST
INCON TS-STS SUMP TESTER +/-0.0001
+0.0004
9. COMMENTS
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