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UNDERG r 4RAGE TANK <br /> SECONDARY COIWTAINMEIW��, REPORT FORM (Page 1 of 6) <br /> Type of Action ❑ Installation Test ❑ Rep*'111pst ❑Six Month Test IN 36 Month Test <br /> I. FAC r TION <br /> CERS ID Date of Secondary Containment Test <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Business Site Address jCity ZIP Code <br /> l ' s� 1�ZL <br /> II. UNDERGROUND STORAGE TANG. , - TECHNICIA14 INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on ft-iCCCertification.) Phone# <br /> Tony Fontana (209)595 -4489 Ext. <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> A-846288 1064273 5-1-2020 <br /> 111. SUMMARY OF SECO AINMENT TESTING RESULTS <br /> Tank ID: (By tank number,stored product,etc.) A �`7 G� j C D <br /> Tank Containment Wit; s <br /> Tightness Test Result ❑Pass ❑Fail -Pass ❑Fail NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA~ <br /> Product Piping Containment '' <br /> Tightness Test Result Pass ❑Fail ❑ Pass [11 Fail ❑NA E-1Pass El Fail ❑NA El Pass ❑ Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail ❑NOW Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Remote Fill Piping Containmentx <br /> Tightness Test Result ❑Pass ❑Fail Pass ❑Fail A NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail Pass ❑Fail QtNA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail Pass ❑Fail 1%NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA <br /> Communication Test Result ❑Pass ❑Fail ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA <br /> rt t <br /> Turbine/Product Piping Sump ` <br /> Tightness Test Result Pass ❑Fail ❑ Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA <br /> Fill Riser Sump <br /> t ', �447� <br /> A� <br /> Tightness Test Result ❑Pass ❑Fail NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA <br /> Vent/Transition Sump ID: <br /> Tightness Test Result ❑Pass ❑Fail ) "Pass ❑Fail gZNA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> UDC ID: 1 l -z 3� � 4 `� <br /> Tightness Test Result 'Pass ❑Fail ❑ Pass ❑Fail ❑NA 0 Pass ❑Fail ❑NA JVPass ❑ Fail ❑ NA <br /> UDC ID: 5 <br /> Tightness Test Result ❑Pass ❑Fail ❑ ::Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> UDC ID: 9 11 12 <br /> Tightness Test Result ❑Pass ❑Fail ❑ .. :Pass ❑Fail ❑NA 1❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> All items marked"Fail'or"WA"must be explained in their respe4V0WWNTS"section. <br /> IV. CERTIFICATION BY UST SERi#IC :x. =IAN CONDUCTING THIS TESTING <br /> 1 hereby certify that the secondary containment was tested In- wdlance with California Code of Regulations,title 23, <br /> division 3,chapter 16,section 2637 and all the information steed herein is accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System,ID=IdentrAi UST=Underground storage tank,ICC=International Code Council, <br /> NA=Not applicable,UDC=Under-dispenser containment <br />