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01 <br /> UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action ❑Installation Test ❑Repair Test ❑Six Month Test ❑x 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 11/08/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Unified Grocers, Inc. <br /> Business Site Address City ZIP Code <br /> 1990 Piccoli Rd. Stockton 95215 <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 /> Jarrett Flewellyn (714)560-8222 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Dale <br /> 588098 8028164 03-29-2019 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID: (By tank number,stored product etc.) A Diesel B T-2 C T-3 D T-4 <br /> Tank Containment <br /> Tightness Test Result O Pass ❑ Fail ❑ NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA <br /> Product Piping Containment <br /> Tightness Test Result E Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑ Fail E NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑Pass ❑ Fail E NA ❑Pass ❑Fall ❑NA O Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fall ❑NA ❑Pass ❑Fail ❑NA <br /> Vapor Recovery Piping Containment i 4` <br /> Tightness Test Result ❑Pass ❑Fail O NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑ Fail p NA ❑Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Turbine/Product Piping Sump <br /> - <br /> Tightness Test Result E Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Fill Riser Sump r `" <br /> Tightness Test Result ❑Pass ❑ Fail E NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> VENT I TRANSITION SUMP ID: a b C d <br /> Tightness Test Result ❑Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> UDC ID: 1 Diesel 2 3 4 <br /> Tightness Test Result E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑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 /> %a"f&7" <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- <br /> Dispenser Containment <br />