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N- U IVtU m UNDERGROUND STORAGE TANK AUG 19 2020 SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of s) Type of Action ❑ Installation Test ❑Repair Test ❑ Six Month t4dlR0NN. 36 Month Test I. FACILITY INFORMATION .j. ' '�M4767 Date of Secondly CQ aiAr 61est usiness Name 5.ame as Faah me or A- olio usioess As) UU�� LL LLUU awrence �Ivermore Vallona �a orMalorles Bldg. 879 aTT 04i teirral Hollow Road racy Ti9ft II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# Brian Thornton 209-834-0792 Contractor I Tank Tester License# ICC Certification# ICC Certification Expiration Date CSLB #724513 A, C10, HAZ 5024962-UT, UC / U1 2-27-22 / 1-05-21 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number,stored product, etc.) A Unleaded B Diesel C D Tank Containment # Tightness Test Result 0 Pass ❑ Fail ❑ NA M Pass ❑ Fail ❑NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA Product Piping Containment , . "F+;i'w,zap• Y , i , _ + .r,;, ��r�"; Tightness Test Result 0 Pass ❑ Fail ❑NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA Communication Test Result 0 Pass ❑ Fail ❑NA ❑Pass ❑ Fail ®NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA Remote Fill Piping Containment A ., ;-i •r.,Q. a r. ',' i?r✓ n9 ,r.n 1 Tightness Test Result ❑Pass ❑ Fail M NA ❑Pass ❑ Fail M NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑ Fail 0 NA ❑Pass ❑ Fail M NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Vent Piping Containment p» s Tightness Test Result ❑Pass ❑ Fail 0 NA ❑Pass ❑ Fail 0 NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑ Fail 0 NA ❑Pass ❑ Fail 0 NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Vapor Recovery Piping Containment t "` �'. `' " y:x Tightness Test Result ❑Pass ❑ Fail M NA ❑Pass ❑ Fail 0 NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑NA Communication Test Result ❑Pass ❑ Fail 0 NA ❑Pass ❑ Fail 0 NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑NA Turbine i Product Piping Sump Tightness Test Result ®Pass ❑ Fail ❑NA 0 Pass ❑ Fail ❑NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Fill Riser Sump ? MCI, ' > .. Tightness Test Result ❑Pass ❑ Fail M NA ❑Pass ❑ Fail M NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑Fail p NA VENT i TRANSITION SUMP ID: e Unleaded b Diesel C d Tightness Test Result ❑Pass ❑ Fail 0 NA ❑Pass ❑ Fail M NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑Fail ❑NA UDC ID: 1 Unleade 2 Un7eaded 3 Iese 4 Tightness Test Result a Pass ❑ Fail ❑NA M Pass ❑ Fail ❑ NA 0 Pass ❑Fail ❑NA ❑ 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 1 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 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=Irtemational Code Council,NA=Not Applicable,UDC=Under- Dispenser Containment UN-054 www.unidocs.org 116-Rev.06/14118