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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> TyeofAon ❑Installation Test ❑Repair Test ❑Six Month Test ❑x 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 4/9/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Pershing Gas 4 Less <br /> Business Site Address City ZIP Code <br /> 4445 N Pershing Rd. I Stockton 95207 <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 /> Justin Williams (800) 339-9930 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 804904 8819073 9/8/2020 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID: (By tank number,stored product, etc,) A T191 12k gallon B T2 dsl 121k gallon C T3 87 121k gallon D <br /> Tank Containment <br /> Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail O NA ❑ Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Product Piping Containment <br /> Tightness Test Result E Pass ❑ Fail ❑ NA O Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> Communication Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑ Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Turbine 1 Product Piping Sump <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑ Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> VENT/TRANSITION SUMP ID: a b C d <br /> Tightness Test Result ❑Pass ❑ Fail p NA ❑Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID: 1 1-2 2 3-4 3 5-6 4 7-8 <br /> Tightness Test Result E Pass ❑ Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E 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 /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations,Title 23,Division <br /> 3,Chapter 16,Section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council.NA=Not Applicable,UDC=Under- <br /> Dispenser Containment <br /> UN-054 www.unidocs.org 1/6-Rev.06114/18 <br />