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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 10181447 12/9/2019 Business Name(Same as Facility Name or DBA-Doing Business A3 " Speedway/Mobil 4681 Business Site Address City ZIP Code 2500 W. Lodi ENVIRONMENTAL HEALT Lodi 95242 II. 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 89 C 91 D Diesel Tank Containment Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑ Pass Z Fail ❑ NA ❑Pass Z Fail ❑ NA ❑Pass Z Fail ❑ NA Z Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass Z Fail ❑ NA ❑ Pass Z Fail ❑ NA ❑ Pass Z Fail ❑ NA Z Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑Fail Z NA ❑ Pass ❑ Fail Z NA Communication Test Result ❑Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑Pass ❑Fail Z NA ❑ Pass ❑ Fail Z NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA Communication Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑Fail Z NA ❑ Pass ❑ Fail Z NA ❑Pass ❑ Fail Z NA ❑ Pass ❑Fail Z NA Communication Test Result ❑ Pass ❑Fail Z NA ❑ Pass ❑Fail Z NA ❑Pass ❑ Fail Z NA ❑ Pass ❑Fail Z NA Turbine/Product Piping Sump Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass Z Fail ❑ NA Fill Riser Sump Tightness Test Result Z Pass ❑Fail ❑ NA Z Pass ❑ Fail ❑ NA 2 Pass ❑ Fail ❑ NA Z Pass ❑Fail ❑ NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑ NA ❑ Pass ❑Fail ❑ NA UDC ID: 1 1/2 23/4 35/6 47/8 Tightness Test Result ❑ Pass Z Fail ❑ NA ❑ Pass Z Fail ❑ NA ❑Pass Z Fail ❑ NA Z Pass ❑ Fail ❑ NA UDC ID: 59/10 611/12 7 8 Tightness Test Result Z Pass ❑ Fail ❑ NA Z 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"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 California Code of Regulations,Title 23,Division 3 Chapter 16,Section 2637 and all the information contained herein is accurate. UST Service Technician Signature _. CERS=California Environmental Reporting System,ID=Identificabon,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- Dispenser Containment