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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑Installation Test ❑Repair Test ❑Six Month Test Q 36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10166883 10/23/2018 Business Name(Same as Facility Name or DBA-Doing Business As) Super Stores Industries Business Site Address City ZIP Code 16888 Mckinley Ave. Lathrop 95330 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# Benjamin Duncan (707) 621-0378 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date Afford-a-test/90-1120 I 5246802-UT 4/3/2019 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product, etc.) A T-1-Diesel B T-2-Diesel C T-3-New Oil D T-4-Used Oil Tank Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑ Pass ❑Fail E NA Product Piping Containment Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑ Fail ❑ NA E Pass ❑Fail ❑NA ❑Pass ❑Fail Z NA Communication Test Result Z Pass ❑ Fail ❑NA Z Pass ❑Fail ❑NA Z Pass ❑Fail ❑NA ❑ Pass ❑Fail E NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail E NA ❑ Pass ❑ Fail E NA ❑Pass ❑Fail E NA Z Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail Z NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA E Pass ❑Fail ❑NA Vent Piping Containment Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail E NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑ Fail Z NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA Turbine/Product Piping Sump Tightness Test Result Z Pass ❑ Fail ❑NA E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA E Pass ❑Fail ❑NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail O NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA UDC ID: 1 1&2 2 3&4 3 4 Tightness Test Result E Pass ❑Fail ❑NA Z Pass ❑ Fail ❑NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA UDC ID: j 5 6 7 8 Tightness Test Result ❑Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA UDC ID: 9 10 11 12 Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA LEI Pass ❑ Fail ❑NA All items marked"Fail'or"NA"must be explained in their respective"COMMENTS"section. ,.._ IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDING THIS TESTING I hereby certify that the secondary containment was tested in accordance with Californ C'oft"of Regulations,Title 23, Division 3,Chapter 16,Section 2637 and all the information contained herein is accurate. UST Service Technician Signature ��e� � �alJuusacr�sa� CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=IrTtematiC*MRQRMENVA6itOUnde, Dispenser Containment DEPARTMENT