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UNDERGROUNDSTORAGETANK SECONDARY CONTAINMENT TESTING REPORT FORM (Pagel 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 10181251 3/19/2019 Business Name(Same as Facility Name or DBA-Doing Business As) CD&R-Tracy Boulevard Chevron Business Site Address City ZIP Code 3775 North Tracy Boulevard Tracy 195376 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# Benjamin Duncan (707) 621-0378 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date Afford-a-test/90-1120 5246802-UT 4/3/2019 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product,etc.) A T-1-Diesel B T-2-91 C T-3-87 D Tank Containment Tightness Test Result O Pass ❑Fail ❑NA O Pass ❑ Fail ❑NA E Pass ❑Fail ❑ NA ❑ Pass ❑Fail ❑ NA Product Piping Containment Tightness Test Result O Pass ❑Fail ❑NA O Pass ❑ Fail ❑NA E Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail O NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑ Pass ❑Fail Z NA Vent Piping Containment Tightness Test Result ❑ Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑Fail E NA ❑ Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA Communication Test Result ❑Pass ❑Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑Fail E NA ❑Pass ❑Fail E NA Turbine/Product Piping Sump Tightness Test Result Z Pass ❑ Fail ❑NA Z Pass ❑ Fail ❑NA Z Pass ❑Fail ❑NA ❑ Pass ❑ Fail ❑NA Fill Riser Sump Tightness Test Result p Pass ❑Fail ❑NA E Pass ❑Fail ❑ NA E Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑ Pass ❑Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑Pass ❑ Fail Z NA UDC ID: 1 1&2 2 3&4 3 5&6 4 7&8 Tightness Test Result E Pass ❑ Fail ❑NA Z Pass ❑ Fail ❑NA Z Pass ❑ Fail ❑NA E Pass ❑Fail ❑NA UDC ID: 5 9&10 6 11&12 7 8 Tightness Test Result Z Pass ❑Fail ❑NA [9 Pass ❑Fail ❑NA �;,.QFail L:,] NA ❑ Pass []Fail [INA UDC ID: 9 10 1 s 12 Tightness Test Result El Pass El Fail ❑ NA ❑Pass ❑ Fail ❑ NA ❑Pass ❑Fail ❑ NA ❑ Pass [ Fal 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 Californi" f egplations,Title 23,Division 3,Chapter 16,Section 2637 and all the information contained herein is accurate. �i`t ��NMENTAI._ HEALTH UST Service Technician Signature DEPARTMENT CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- Dispenser Containment