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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 CERS ID Date of Secondary Containment Test 7-20-20 Business Name(Same as Facility Name or DBA-Doing Business As) Safeway fueling station Business Site Address City ZIP Code 2808 Country Club Blvd Stockton 95204 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification.) Phone# Adam Taylor (559)553 - 5420 Ext. Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 1028900 8143455 12-29-20 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID: (By tank number,stored product, etc.) A 87 B 91 C Diesel D Tank Containment Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NAElPass El Fail El NA Product Piping Containment Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NAElPass ElFail ElNA Communication Test Result ElPass ElFail ® NA ElPass ElFail ® NA ElPass ElFail ® NA I ❑ Pass ❑ Fail ❑ NA Turbine/Product Piping Sump Tightness Test Result ❑ Pass ❑ Fail M NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail ® NA ® Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Vent/Transition Sump ID: a b C d Tightness Test Result ❑ Pass ❑ Fail ® 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 ® NAElPass ElFail ® NA ElPass ElFail ® NA ElPass ElFail ElNA UDC ID: 9 10 Ill 12 Tightness Test Result ❑ Pass ElFail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA 1 ❑ Pass ❑ Fail ❑ NA All items marked"Fail'or"N/A"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=International Code Council, NA=Not applicable, UDC=Under-dispenser containment