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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 ❑x 36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10180623 3/20/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Countryside Liquor& Gas Business Site Address City ZIP Code 14971 North Hwy. 88 Lodi 95240 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC 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-Regular 87 B T-2-Super 91 C T-3-Diesel D Tank Containment Tightness Test Result E Pass ❑ Fail ❑NA E Pass ❑Fail ❑NA O Pass ❑ Fail ❑ NA ❑Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA E 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 p NA ❑Pass ❑Fail E NA ❑Pass ❑Fail O NA ❑Pass ❑Fail O NA Communication Test Result ❑Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑Pass ❑Fail O NA ❑Pass ❑Fail E NA Vent Piping Containment Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑ Fail E NA ❑Pass ❑Fail O NA ❑Pass ❑Fail O 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 17 NA ❑Pass ❑Fail E NA Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail O NA ❑Pass ❑Fail E NA Turbine/Product Piping Sump Tightness Test Result O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA Fill Riser Sump Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail O NA ❑Pass ❑ Fail E NA ❑Pass ❑ Fail E NA UDC ID: 1 1&2 2 3&4 3 4 Tightness Test Result E 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 E] Pass E] Fail ❑ NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail EEINA11 ❑Pass El ❑NA All items marked"Fail'or"NA"must be explained in their respective"COMMENTS"section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCT TWS TESTING I hereby certify that the secondary containment was tested in accordance with California C f Regulations,Title 23,Divis 9 3,Chapter 16,Section 2637 and all the information contained herein is accurate. UST Service Technician Signature —W7r�ia saar�a� �;;R 2 5 2019 CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=�Jgderr Dispenser Containment ENV I R O N M E N '+,- - � I"7 DEPARTMENT