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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT <br /> Type of Action: ❑ Installation Test ❑ Repair Test ® 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Test: 11/27/2019 <br /> Business Name: Arco AmPm Cherokee <br /> Site Address: City Zip Code <br /> 900 S Cherokee Lane Lodi <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Technician: Phone#: <br /> Rob Jacobs 916-693-0555 <br /> Contractor License#: ICC Certification ID: ICC Expiration Date: <br /> 433159 9943 5/10/2020 <br /> 111. SUMMARY OF SECONDARY TESTING RESULTS <br /> TANK ID: A DSL B C D <br /> Tank Containment(Annular) <br /> Tightness Test Results ®Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Product Piping Containment(Sec Line) <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail Q NA ❑Pass❑Fail❑NA <br /> Communication Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Results Q Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass L]Fail❑NA Q Pass El Fail❑NA <br /> Communication Test Results Q Pass Q Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Vent Piping Containment <br /> Tightness Test Results ❑Pass❑Fail❑NA Q Pass❑Fail❑NA ❑Pass❑Fail❑NA MoFail <br /> Communication Test Results ❑Pass❑Fail❑NA ❑Pass❑Fail(]NA ❑Pass❑Fail❑NA <br /> Vapor Recovery Piping Containment(Sec) <br /> Tightness Test Results ❑Pass❑Fail❑NA Q Pass❑Fail❑NA ❑Pass❑Fail Q NA ❑Pass Q Fail Q NA <br /> Communication Test Results ❑Pass❑Fail❑NA Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Turbine/Product Piping Sump(STP) <br /> Tightness Test Results ❑Pass❑Fail❑NA ❑ Pass❑Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> Fill Riser Sump <br /> ❑ <br /> Tightness Test Results Pass E]Fail❑NA ❑Pass E]Fail❑NA ❑Pass E]Fail❑NA E]Pass❑Fail❑NA <br /> VENT/TRANSITION SUMP ID: a b c d <br /> Tightness Test Results E]Pass❑Fail❑NA Q Pass Q Fail❑NA ❑Pass❑Fail❑NA ❑Pass❑Fail❑NA <br /> UDC ID: 1 2 3 4 <br /> Tightness Test Results ❑Pass❑Fail❑NA EP ss❑Fail❑NA <br /> E]Pass E]Fail❑NA ❑Pass❑fail❑NA <br /> UDC ID: S 7 8 <br /> Tightness Test Results [I Pass E]Fail❑NA ss El Fail❑NA ❑Pass E]Fail❑NA ❑Pass❑Fail❑NA <br /> UDC ID: 9 _ 11 12 <br /> Tightness Test Results ❑Pass❑Fail❑NAss Fail❑NAEl Pass El Fail❑NA Q 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 /> hearby certify that the secondary containment was tested in accordance with California Code of Regulations,Title 23,Division 3,Section <br /> 2637 and all the information contained herein is accurate <br /> UST Service Technician ignature <br /> rF� <br /> ENVIRONMENTAL HEALTH <br />