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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 N 36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10181019 04/12/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Tracy Market Business Site Address [Tracy, ity ZIP Code 15 E. Grant Line Road CA 95376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification.) Phone# Nik Zagorov (888)500 - 2435 Ext.2 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 958763 5264361 05/08/2019 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID:(By tank number,stored product,etc.) A Regular B Regular Syp. C Super Tank Containment Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail E NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail E NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA Vent Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail N NA Vapor Recovery Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail N NA Turbine/Product Piping Sump Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑NA N Pass ❑ Fail ❑NA Fill Riser Sump Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑NA Vent/Transition Sump ID: a Vent BOX b C d Tightness Test Result N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA UDC ID: 1 1-2 23-4 35-6 Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑NA ❑ Pass ❑ Fail N NA UDC ID: 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail N NA ❑Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑Fail N NA UDC ID: 9 10 11 12 Tightness Test Result ❑ Pass ❑ Fail E NA P Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail N 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 N row CERS=California Environmental I i,UST=Underground storage tank:,ICC=International Code Council, NA=Not applicable,UDC=Under-dispenser containment