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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑Six Month Test N 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10181065 12/02/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> North Pole <br /> Business Site Address City ZIP Code <br /> 574 W. Grant Line Road Tracy, CA 95376 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# <br /> Marco Alejos (888)500 - 2435 Ext.2 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> 958763 8415074 04/27/2021 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> Tank ID: (By tank number, stored product,etc.) A 87 B 91 <br /> Tank Containment <br /> Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Turbine/Product Piping Sump <br /> Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> Vent/Transition Sump ID: a b C d <br /> Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> UDC ID: 1 1-2 23-4 35-6 47-8 <br /> Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> UDC ID: J 10 11 12 <br /> Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA <br /> All items marked"Fail'or"N/A"must be explained in their respective"COMMENTS"section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations,title 23, <br /> division 3,chapter 16,section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Rel cation,UST=Underground storage tank,ICC=International Code Council, <br /> NA=Not applicable,UDC=Under-dispenser containment <br />