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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 F City ZIP Code 15 E . Grant Line Road I Tracy , CA 95376 If . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC 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 : (Bytanknumber, storedproduct, 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 N NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA Vent 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 N NA Vapor Recovery 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 N NA i Turbine / Product Piping Sump Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA j 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 N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA UDC ID : 1 1 -2 2 3-4 3 5-6 4 Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail N NA UDC ID : 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail t[DNA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA UDC ID : 9 10 11 12 Tightness Test Result ❑ Pass ❑ Fail A ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N 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 prof/ CERS = California Environmental I n, UST = Underground storage tank, ICC = International Code Council, NA = Not applicable, UDC = Under-dispenser containment 'i