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UNDERGROUNDSTORAGETANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Pagel of 6) <br /> Type of Action ❑Installation Test M Repair Test ❑Six Month Test ❑36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 11/13/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Angle Petroleum <br /> Business Site Address City ZIP Code <br /> 7700 Moreland St Stockton 195212 <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 /> Michal Kennard (209) 461-6337 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 1001331 A-HAZ S �� /� �;= 7 1-2 I <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID:(By tank number,stored product,etc.) A 87 B Diesel I F-C D <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 [INA <br /> Remote Fill 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 /> 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 as ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Fill Riser Sump <br /> Tightness Test Result ®Pass ❑Fail ❑NA p Pass ❑Fail ❑ NAI ❑ Pass ❑Fail ❑NAI ❑Pass ❑Fail [-INA <br /> VENT I 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 ❑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 CONDUCTING THIS TESTING <br /> hereby certify that the secondary containment was tested in accordance with Californ' I ' tle <br /> 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 COZ- -;,NA=Not Applicable,UDC=Under- <br /> Dispenser Containment <br /> ENViRONIVIENTA I`EAL.T H <br /> DFPARTMFN-F <br />