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IRSPteltfsn to �Joam /q vlaow UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page i of 6) Type of Action ❑ Installation Test 0 Repair Test ❑ Six Month Test ❑ 36 Month Test 1. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 12/21/2020 Business Name (Same as Facility Name or DBA -Doing Business As) North Pole Gas Business Site Address 574 W Grant Line Rd CityZIP Trac Code 95376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Mike Kennard Phone # (209) 461-6337 Contractor I Tank Tester License # 1001331 A-HAZ ICC Certification # ICC Certification Expiration Date III.SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product, etc.) A UDC 1 / 2 B UDC 3 / 4 C UDC 5 / 6 D UDC 7 / 8 Tank Containment Tightness Test Result ❑ Pass D Fail D NA D Pass ❑ Fail ❑ NA D Pass ❑ Fail ❑ NA D Pass D Fail D NA Product Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA D Pass ❑ Fail ❑ NA ❑ Pass D Fail ❑ NA ❑ Pass D Fail D NA Communication Test Result ❑ Pass ❑ Fail D NA D Pass ❑ Fail DNA D Pass D Fail D NA ❑ Pass D Fail D NA Remote Fill Piping Containment Tightness Test Result D Pass D Fail ❑ NA D Pass D Fail D NA D Pass ❑ Fail ❑ NA D Pass ❑ Fail D NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail D NA D Pass D Fail ❑ NA ❑ Pass ❑ Fail D NA Vent Piping Containment Tightness Test Result D Pass D Fail ❑ NA ❑ Pass D Fail D NA ❑ Pass D Fail D NA D Pass D Fail D NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass D Fail D NA ❑ Pass D Fail ❑ NA ❑ Pass ❑ Fail D NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass D Fail ❑ NA ❑ Pass D Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail D NA ❑ Pass ❑ Fail ❑ NA ❑ Pass D Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine I Product Piping Sump Tightness Test Result ❑ Pass D Fail ❑ NA ❑ Pass D Fail ❑ NA ❑ Pass ❑ Fail D NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail D NA ❑ Pass ❑ Fail D NA ❑ Pass ❑ Fail ❑ NA D Pass D Fail ❑ NA VENT I TRANSITION SUMP ID: a b C d Tightness Test Result ❑ Pass D Fail D NA ❑ Pass D Fail ❑ NA D Pass D Fail D NA ❑ Pass ❑ Fail ❑ NA UDC ID: 1 1 2 3 /-{ 3 —V> (� 4 Tightness Test Result All 21 Pass D Fail ❑ NA Pass Fail ❑ NA - Pass D Fail ❑ NA rX. Pass ❑ Fail D NA UDC ID: 5 6 7 8 Tightness Test Result D Pass D Fail ❑ NA D Pass D Fail ❑ NA D Pass ❑ Fail ❑ NA D Pass D Fail ❑ NA UDC ID: 9 10 11 1 12 Tightness Test Result D Pass ❑ Fail DNA D Pass ❑ Fail ❑ NA ❑Pass ❑Fail D NA I D Pass D 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 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 Z";t 7. 12/21/2020 CERS = California Environmental Reparfmg System, ID = IdentiRcation, UST= Underground Storage Tank, ICC = Intemaki al Code Council, NA= Not Applicable, UDC = Under - Dispenser Contaimant