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UNDERGROUNDSTORAGETANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page t of 6) Type of Action ❑ Installation Test ❑ Repair Test m Six Month Test 36 Month Test I. FACILITY INFORMATION CERS ID 10156819 I Date of Secondary Conta nt Test 11/7/2018 Business Name (Same as Facilely Name or DBA -Doing Business As) Safeway 2600 Business Site Address 1987 W. 11th St. City Tracy ZIP Code 95376 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Michael McCarter Phone # (707) 545-5522 Contractor / Tank Tester License # Able Maintenance, Inc. -312844 ICC Certification 0 8819839 ICC Certification Expiration Date 10/25/2019 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (Bytank number, storedproduct etc.) A 87 B 91 C Diesel D Tank Containment Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA D Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA D Pass D Fail D NA Communication Test Result D Pass ❑ Fail 0 NA D Pass ❑ Fail m NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA D Pass ❑ Fail <a NA ❑ Pass ❑ Fail m NA D Pass ❑ Fail ❑ NA Communication Test Result D Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result D Pass ❑ Fail 0 NA ❑ Pass ❑ Fail m NA D Pass ❑ Fail 0 NA D Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail m NA D Pass ❑ Fail 0 NA D Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA D Pass ❑ Fail 0 NA D Pass D Fail 0 NA D Pass D Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA D Pass D Fail 0 NA D Pass D Fail 0 NA D Pass D Fail ❑ NA Turbine I Product Piping Sump Tightness Test Result ❑ Pass ❑ Fail 0 NA D Pass ❑ Fail 0 NA D Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result D Pass D Fail 0 NA D Pass D Fail 0 NA D Pass ❑ Fail 0 NA D Pass ❑ Fail ❑ NA VENT I TRANSITION SUMP ID: a b C d Tightness Test Result D Pass ❑ Fail 0 NA D Pass D Fail 0 NA D Pass D Fail 0 NA D Pass D Fail D NA UDC ID: 17-8 213-14 3 4 Tightness Test Result 0 Pass ❑ Fail D NA 0 Pass D Fail ❑ NA D Pass ❑ Fail D NA D Pass D Fail D NA UDC ID: 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail D NA D Pass ❑ Fail ❑ NA D Pass ❑ Fail D NA 1 D Pass ❑ Fail ❑ NA UDC ID: 9 1 10 11 1 12 Tightness Test Result ❑ Pass ❑ Fail D NA D Pass D Fail ❑ NA D Pass ❑ Fail ❑ NA 1 D Pass D Fail ❑ NA All items marked "Fail" or "NA" must be explained in their respective "COMMENTS" section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, Title 23, Division 3, Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Counul, NA = Not Applirable, UDC = Under- Dspenser Containment