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UNDERGROUND STORAGE TANK 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 10181059 6/20/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Quik Stop #138 Business Site Address City ZIP Code 1153 Lincoln Blvd. Trapy 95376 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# Juan Jauregui (916) 372-1888 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 617238 5246964 8/30/2019 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product,etc.) A Gasoline - 87 B Gasoline - 89 C Gasoline -91 D Tank Containment Tightness Test Result Z Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA E Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail Z NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑ Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA Vent Piping Containment Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail Z NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA Communication Test Result ❑ Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑ Pass ❑Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA Turbine/Product Piping Sump Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail Z NA ❑Pass ❑ Fail E NA ❑Pass ❑ Fail E NA ❑ Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA UDC ID: 1 Disp#1-2 2 Disp#34 3 4 Tightness Test Result O Pass ❑ Fail ❑NA E Pass ❑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 El ❑NA El Pass El 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 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 qaz-,A�- CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- Disperser Containment