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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action ❑ Installation Test ® Repair Test ❑ Six Month Test ❑ 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 02-09-19 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> ARCO #7147 <br /> Business Site Address City ZIP Code <br /> 1206 E. MARCH LANE � STOCKTON <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> DAVID ROUSE (916) - 826 Ext. 6176 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 8292530 06-28-20 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> Tank ID: (By tank number, stored product, etc.) A T1: B T2: C T3: DIESEL D <br /> UNLEADED PREMIUM <br /> Tank Containment <br /> Tightness Test Result ® Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NAElPass El Fail El NA <br /> Communication Test Result <br /> El ❑ Fail El NA El Pass El Fail El NA El Pass El Fail El NA ElPass El Fail El NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Turbine/Product Piping Sump <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Vent/Transition Sump ID: a b c d <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID: 1 2 3 4 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID: 9 10 11 12 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA I ❑ Pass ❑ Fail ❑ NA <br /> All items marked"Fail'or"N/A"must be explained in their respective"COMMENTS"section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, title 23, <br /> division 3,chapter 16,section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System, ID=Identification,UST=Underground storage tank,ICC=International Code Council, <br /> NA=Not applicable,UDC=Under-dispenser containment <br />