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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑Installation Test ❑ Repair Test ❑Six Month Test ®36 Month Test I. FACILITY INFORMATION C16T?4767 Date of Secondn-2r�iArAe,MTest usiness Name Same as Fadli me orQSA-Qoin ¢usiaess As) VV// LL LLUU��UU wrence ivermore a lona a olFa orieS Bldg. 882 f3t�,sjp��lte t8s ral Hollow Road racy 285376 1 W 11. 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/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 Diesel B C D Tank Containment Tightness Test Result ®Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Product Piping Containment Tightness Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result la Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail 0 NA ❑Pass p Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA Communication Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Vent Piping Containment Tightness Test Result ❑Pass ❑ Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA Communication Test Result ❑Pass ❑Fail B NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑ NA Turbine/Product Piping Sump Tightness Test Result 0 Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA FIII Riser Sump Tightness Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a Uiesel b C d Tightness Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA UDC ID: 1 2 3 4 Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑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 11 12 Tightness Test Result ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA I ❑Pass ❑Fail ❑NA All Items marked"Fall"or"NA"must be explained/n their respective"COMMENTS"section. N. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING 1 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 EnviDnmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Appkable,UDC=Under- Dispenser Containment UN-064 www.unidocs.org 116-Rev.06/14/18