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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 Z 36 Month Test i . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10180967 9/26/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Quik Stop Market # 144 Business Site Address City ZIP Code 7272 West Ln Stockton 195210 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Anthony Reyes (916 ) 373 - 1166 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 617238 8293772 9/ 16/2020 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (Bytanknumber, storedproduct, etc.) A 87 Gasoline B 89 Gasoline C 91 Gasoline D Tank Containment Tightness Test Result Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail ENA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass El Fail ENA ❑ Pass ❑ Fail ENA ❑ Pass El Fail ENA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID: a b C d Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 1 -2 2 34 3 5 -6 4 Tightness Test Result E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA E 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 ❑ Pass ❑ Fail ❑ NA All items marked "Fail' or "NA " must be explained in their respective "COMMENTS" section. IV. 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 A nfi CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- Dispenser Containment