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RECEIVED <br /> UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (P <br /> Type of Action ❑Installation Test ❑Repair Test ❑Six Month Test I)EIRARTT <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10181401 8/3/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Van De Pol Enterprises/Pacific Pride <br /> Business Site Address City ZIP Code <br /> 351 North Beckman Road Lodi 95240 <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 /> Benjamin Duncan (707) 621-0378 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Tank Tester License #90-1120 5246802-UT 3/21/2021 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID: (By tank number,stored product,etc.) A T-1-Red Diesel B T-2-Super 91 C T-3-Regular 87 D T-4-Clear Diesel <br /> Tank Containment <br /> Tightness Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA R Pass ❑Fail ❑ NA O Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result R Pass ❑Fail ❑ NA 0 Pass ❑ Fail ❑ NA R Pass ❑Fail ❑NA R Pass ❑Fail ❑ NA <br /> Communication Test Result O Pass ❑Fail ❑NA El Pass ❑ Fail ❑ NA R Pass ❑Fail ❑ NA R Pass ❑Fail ❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail p NA ❑Pass ❑ Fail O NA ❑Pass ❑Fail p NA ❑Pass ❑Fail EI NA <br /> Communication Test Result ❑Pass ❑Fail R NA ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail R NA <br /> Vent Piping Containment <br /> Tightness Test Result R Pass ❑Fail ❑NA O Pass ❑Fail ❑ NA N Pass ❑Fail ❑NA O Pass ❑Fail ❑NA <br /> Communication Test Result R Pass ❑Fail ❑ NA R Pass ❑Fail ❑NA R Pass ❑Fail ❑NA R Pass ❑Fail ❑ NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail O NA R Pass ❑ Fail ❑NA R Pass ❑Fail ❑NA ❑ Pass ❑Fail R NA <br /> Communication Test Result ❑Pass ❑Fail R NA O Pass ❑ Fail ❑NA R Pass ❑Fail ❑NA ❑ Pass ❑Fail O NA <br /> Turbine/Product Piping Sump <br /> Tightness Test Result O Pass ❑Fail ❑ NA R Pass ❑ Fail ❑ NA R Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result R Pass ❑Fail ❑NA R Pass ❑Fail ❑ NA R Pass ❑ Fail ❑NA R Pass ❑Fail ❑NA <br /> VENT/TRANSITION SUMP ID: a Vent Sump all Products b C d <br /> Tightness Test Result R Pass ❑Fail ❑NA ❑Pass ❑Fail R NA ❑Pass ❑Fail R NA ❑Pass ❑Fail R NA <br /> UDC ID: 1 1&2 2 3&4 3 5&6 4 7&8 <br /> Tightness Test Result R Pass ❑ Fail ❑NA O Pass ❑ Fail ❑NA El Pass ❑Fail ❑NA R Pass ❑Fail ❑NA <br /> UDC ID: 5 9&106 7 8 <br /> Tightness Test Result R Pass El Fail ❑NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> UDC ID: 9 10 11 12 <br /> Tightness Test Result E]Pass ❑Fail ❑NA ❑ Pass ❑ Fail E] NA ❑ Pass [I 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 informationcontainedherein is accurate. <br /> UST Service Technician Signature <br /> CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- <br /> Dispenser Containment <br />