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UNDERGROUNDSTORAGETANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑Installation Test ❑X Repair Test ❑Six Month Test ❑36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10181251 1 11/14/2019 Business Name(Same as Facility Name or DBA-Doing Business As) CD&R-Tracy Boulevard Chevron Business Site Address City ZIP Code 3775 North Tracy Boulevard Trac 95376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# Benjamin Duncan (707) 621-0378 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date Tank Tester License #90-1120 5246802-UT 3/21/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product.etc.) A T-1-Diesel B T-2-91 C T-3-87 D Tank Containment Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑ Fail Z NA ❑Pass ❑ Fail ❑ NA Communication Test Result ❑Pass ❑ Fail E NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail E NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑ Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail ❑NA Vent Piping Containment Tightness Test Result ❑Pass ❑Fail Z NA ❑Pass ❑ Fail Z NA ❑Pass ❑Fail E NA ❑Pass ❑ Fail ❑ NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA ❑Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail 21 NA ❑Pass ❑Fail ❑NA Turbine/Product Piping Sump Tightness Test Result ❑Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑Fail Z NA ❑ Pass ❑Fail ❑ NA Fill Riser Sump Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA ❑ Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail ❑NA UDC ID: 1 1&2 2 3&4 3 5&6 4 7&8 Tightness Test Result ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail Z NA UDC ID: 5 9&10 6 11&12 7 8 Tightness Test Result ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA UDC ID: 9 10 11 12 Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑ Fail ❑ NA ❑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 Californi dexiimegI itlg. ion 3,Chapter 16,Section 2637 and all the informations contained herein is accurate. UST Service Technician Signature L. ,j I 1 V tyaaa'a CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Couna, A—Nit 4VUble,UDC=Under- Dispenser Containment ENVIRONMENTAL HEALTH DEPARTMENT