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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 10181229 12/11 /2019 Business Name (Same as Facility Name or DBA-Doing Business As) Speedway / Shell 4873 Business Site Address City ZIP Code 35 N . Cherokee Ln , Lodi 95240 IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Michael McCarter (707) 545-5522 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date Able Maintenance , Inc. - 312844 8819839 10/15/2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product, etc.) A 87 B 91 C Diesel rPass Tank Containment Tightness Test Result ® Pass E] Fail ❑ NA ® Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ❑ Fail ❑ NA Product Piping Containment Tightness Test Result m Pass ❑ Fail ❑ NA m Pass ❑ Fail ❑ NA m Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result m Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA m Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fall ® NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail m 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 ® NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result m Pass ❑ Fail ❑ NA m Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ® 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 ❑ Pass m Fail ❑ NA ® Pass ❑ Fail ❑ NA ® 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 ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA All items marked "Fall' or "NA " must be explained in their respective "COMMENTS" section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING - 0-- 4 IRA- I hereby certify that the secondary containment was tested in accordance with Calif rn o f u a o s vision et 3, Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature �. DF , 2t� 19 CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- Dispenser Containment ENVIRONMENTAL HEALTH