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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test 9 36 Month Test 1 . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10594654 3/ 18/2020 Business Name (Same as Facility Name or DBA-Doing Business As) CRM - Pacific Avenue Chevron Business Site Address City ZIP Code 6633 Pacific Avenue Stockton 195207 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 524680MT 3/21 /2021 111 . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (Bytanknumber, stored product, etc.) A T- 1 -Supreme 91 B T-2- Regular 87 C T-3- Regular 87 D Tank Containment Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill 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 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 E 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 E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 1 &2 2 3 &4 3 5&6 4 7&8 Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA UDC ID : 5 9& 10 6 11 & 12 7 8 Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass all ❑ 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 "Fall" or "NA " must be explained in their respective "COMMENTS" section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CON W1 ING,THIS TESTING S I hereby certify that the secondary containment was tested in accordance with Califo nib 0,pde "bf zRiedtilatibiris , Title 23 , Division 3 , Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signaturefj � li �� CERS = Califomia Environmental Reporting System, ID = Identification, Um ST = Underground Storage Tank, ICC = Intern r l Pdg U pl NAS NOtApplica (e tJ = Under- Dispenser Containment ' `