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UNDERGROUNDSTORAGETANK SECONDARY CONTAINMENT TESTING REPORT FORM (Pagel of 6) Type of Action ❑ Installation Test ❑Repair Test ❑Six Month Test 0 36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 4/9/2020 Business Name(Same as Facility Name or DBA-Doing Business As) Pershing Gas 4 Less Business Site Address City ZIP Code 4445 N Pershing Rd. Stockton 195207 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# Justin Williams (800) 339-9930 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 804904 8819073 9/8/2020 111. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID:(By tank number,stored product, etc.) A T191 12k gallon B T2 dsl 12k gallon C T3 87 12k gallon D Tank Containment Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail Z NA ❑Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA Product Piping Containment Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑Fail ❑NA O Pass ❑ Fail ❑NA ❑ Pass ❑Fail ❑NA Communication Test Result Z Pass ❑ Fail ❑NA Z Pass ❑Fail ❑NA Z Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail O NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA Communication Test Result ❑ Pass ❑Fail Z NA ❑Pass ❑Fail p NA ❑Pass ❑Fail Z NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑Pass ❑Fail O NA ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑Fail E NA ❑Pass ❑Fail O NA ❑Pass ❑Fail Z NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑Fail O NA ❑Pass ❑Fail Z NA ❑ Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA Communication Test Result ❑Pass ❑Fail Z NA ❑Pass ❑Fail Z NA I ❑ Pass ❑Fail Z NA ❑ Pass ❑ Fail ❑ NA Turbine/Product Piping Sump Tightness Test Result E Pass ❑ Fail ❑NA Z Pass 01 ail ❑NA Z Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑Pass ❑Fail Z 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 p NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑ NA UDC ID: 1 1-2 2 3-4 3 5-6 4 7-8 Tightness Test Result El Pass ❑ Fail ❑NA Z Pass ❑Fail ❑NA El Pass ❑Fail ❑NA E Pass ❑ Fail ❑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 ❑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,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- Dispenser Containment UN-054 www.unidocs.org 1/6-Rev.06/14/18