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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 10184365 1 / 15/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Food 4 Less Fuel Center Business Site Address City ZIP Code 3408 Manthey Road Stockton 90609 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Eusebio Sousa (707 ) 545-5522 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date Able Maintenance , Inc. - 312844 5254516 7/ 12/2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) A 87 B 91 C D Tank Containment Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result m Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ 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 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 Tightness Test Result ❑ Pass ❑ Fail IZ NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail m NA ❑ Pass [:] Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail m 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 lZ NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 11 /2 2 3/4 35/6 47/8 Tightness Test Result m Pass ❑ Fail ❑ NA m Pass ❑ Fail ❑ NA m Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA UDC ID : 59/ 10 6 7 8 Tightness Test Result ® Pass ❑ Fail ❑ NA ❑ Pass [I Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 9 10 11 12 Tightness Test Result E] Pass ❑ Fail E] NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA E] Pass [I Fail [] _NA All items marked "Fail' or "NA " must be explained in their respective "COMMENTS " section. j 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 / 11 CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code'a n I }JAY Not APplic� 1[ sUnder- Dispenser Containmentr 64 f