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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑Installation Test Z Repair Test ❑Six Month Test ❑36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 3/3/2020 Business Name(Same as Facility Name or DBA-Doing Business As) Pilot 618 Flying J Business Site Address City ZIP Code 1501 N. Jacktone Rd. Ripon _ 95366 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone tr Jacob Weaver (877) 972-7581 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 804431 7 8338858-UC 2/14/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank numher.stored product.etc.) A RV Auto DSL B C D Tank Containment Tightness Test Result ❑Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA ❑Pass ❑ Fail ❑ NA ❑ Pass ❑Fad ❑NA Product Piping Containment Tightness Test Result El Pass ❑ Fail ❑ NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA Communication Test Result E)Pass ❑ Fail ❑NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑ NA ❑ Pass ❑Fail ❑NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail p NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑ NA Communication Test Result ❑Pass ❑Fail p NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA Communication Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA ❑Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA Communication Test Result ❑Pass ❑Fail E NA ❑ Pass ❑ Fail ❑ NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Turbine/Product Piping Sump Tightness Test Result ❑ Pass ❑Fail Z NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑NA Fill Riser Sump Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑ Fail ❑ NA ❑ Pass [E] ail ❑ NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA UDC ID: 1 13 2 24 SAT 3 4 Tightness Test Result p Pass [3Fail ❑NA Z Pass E] Fail ❑ NA ❑Pass ElFail ElNA [I Pass El Fail El NA UDC ID: 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 [INA ❑Pass ❑ 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 APR 0 8 «;20 CERS=Califomia Environmental Reporting System,ID=Identification.UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable.UDC=Under- Dispenser Containment ENVIRONIVIEN{AL -A r/+,Li H DEPARTMENT