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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page -I of 6) Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test X 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10181363 11 / 14/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Charter Way Chevron Business Site Address City ZIP Code 508 West Charter Way Stockton 95206 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Benjamin Duncan ( 707 ) 621 -0378 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date Tank Tester License #90 - 1120 5246802 - UT 3/21 /2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (Bytanknumber, storedproduct, etc.) A T- 1 -87- Main B T-2-87-Slave C T-3 -91 D Tank Containment Tightness Test Result p Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result O Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑ NA El Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail H NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail El NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail El NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result p Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 1 &2 2 3&4 3 5&6 4 7&8 Tightness Test Result El Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA El Pass ❑ Fail ❑ NA UDC ID : 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 9 10 11 12 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ FaE] NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA All items marked "Fail" or "NA " must be explained in their respective "COMMENTS" section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING hereby certify that the secondary containment was tested in accordance with Califoa t' s , vision 3 , Chapter 16, Section 2637 and all the informations contained herein is accurate. OlVe UST Service Technician Signature h . CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, A = Not, plicable, UDC = Under- Dispenser Containment ENVIRONMENTAL HEALTH n17DADTnflL: Pl t