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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM ( Pagel of 6) Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test 9 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10180643 1 8/8 /2019 Business Name (Same as Facility Name or DBA-Doing Business As) Quik Stop # 125 Business Site Address City ZIP Code 1580 W. Main St Ripon 95366 il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Juan Jauregui ( 916 ) 372 - 1888 Contractor I Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 5246964 8/30/2019 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) A Gasoline - 87 B Gasoline - 91 C Diesel D Tank Containment Tightness Test Result O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass [I Fail ❑ NA UDC ID : 1 Disp # 1 -2 2 Disp #3-4 3 Disp #5-6 4 Tightness Test Result El Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 5 16 7 8 Tightness Test Result ElPass ❑ Fail E] 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 ❑ 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 California Code of Regulations, Title 23 , Division 3 , Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature CERS = California Environmental Reporting System, & Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- Dispenser Containment