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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT <br /> Type of Action: ❑ Installation Test ® Repair Test ❑ 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Test: 2/21/2020 <br /> Business Name: Kwik Sery <br /> Site Address: City Zip Code <br /> 420 W Kettleman Lodi <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Technician: Phone#: <br /> Jeff Raven 916-693-0555 <br /> Contractor License#: ICC Certification ID: ICC Expiration Date: <br /> 433159 9326216 8/31/2022 <br /> III. SUMMARY OF SECONDARY TESTING RESULTS <br /> TANK ID: A 87 B DSL C D <br /> Tank Containment(Annular) <br /> Tightness Test Results ®Pass❑Fail❑NA ®Pass❑Fail❑NA Q Pass❑Fail Q NA ❑Pass❑Fail❑NA <br /> Product Piping Containment(Sec Line) <br /> ❑ <br /> Tightness Test Results Pass E]Fail[INA ❑Pass E]Fail E]NA El Pass E]Fail E]NA Q Pass❑Fail E]NA <br /> Communication Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Results E]Pass E]Fail E]NA E]Pass[:]Fail 1:1 111 E]Pass❑Fail[—]NA E]Pass❑Fail❑NA <br /> Communication Test Results –EPass❑Fail Q NA ElPass ElFail[_]NA Q Pass❑Fail Q NA ❑Pass❑Fail❑NA <br /> Vent Piping Containment <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA El El ❑NA ❑Pass❑Fail❑NA <br /> Communication Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Vapor Recovery Piping Containment(Sec) <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Communication Test Results E]Pass❑Fail E]NA Q Pass E]Fail❑NA ❑Pass ElFail Q NA —0 Pass E]Fail❑NA <br /> Turbine/Product Piping Sump(STP) <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Fill Riser Sump <br /> Tightness Test Results ❑Pass[:1 Fail❑NA E]Pass❑Fail E]NA E]Pass E]Fail❑NA E]Pass❑Fail E]NA <br /> VENT/TRANSITION SUMP ID: a b c d <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> UDC ID: 1 2 3 4 <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA El ❑Fail❑NA Pas ❑Fail❑NA <br /> UDC ID: 9 10 11 12 <br /> Tightness Test Results Pass E]Fail NA Pass❑Fail NA Pass Fail❑NA 1 ❑Pass❑Fail❑NA <br /> All Items marked"Fail'or"NA"must be explained in their respective"Comments section <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CON T G TH S TENTj G <br /> I hearby certify that the secondary containment was tested in accordance with California C uIationIon <br /> 2637 and all the information conta' d Ijerein is accurate <br /> UST Service Technician Signature MlVIM1 y nn <br /> 6 Z02U <br /> ENVIRONMENTAL HEALTH <br /> DEPARTMENT <br />