Laserfiche WebLink
1 <br /> UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test 0 36 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10181303 1 /8/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> California Car Wash Corporation (Zoom ) <br /> Business Site Address City ZIP Code <br /> 3434 East Hammer Lane Stockton 95212 <br /> Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification) Phone # <br /> Benjamin Duncan (707 ) 621 -0378 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Afford -a4est/90- 1120 5246802- UT 4/3/2019 <br /> 1110 SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID : (By tank number, stored product, etc) A T- 1 -87 B T-2-91 C T-3- Diesel D <br /> Tank Containment <br /> Tightness Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> Vent Piping Containment <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result E Pass ❑ Fail ❑ NA E Pass ElFail ❑ NA E Pass E] Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Turbine / Product Piping Sump <br />( Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA [E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ElFail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> VENT / TRANSITION SUMP ID : a Vent Box Sump Fb C d <br /> Tightness Test Result E Pass ElFail ❑ NA ❑ Pass ❑ Fail E NA ❑ Pass ElFail E NA ElPass F1Fail ❑ NA <br /> UDC ID : 1 1 &2 2 3&4 3 5&6 4 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 5 6 7 8 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ElPass ❑ Fail E] NA [IPass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 9 10 11 12 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail r0-1NA 171 Pass El Fail ❑ NA El Pass ❑ Fail ❑ NA <br /> Alf items marked "Fail" or "NA " must be explained in their respective "COMMENTS" section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> 1 hereby certify that the secondary containment was tested in accordance with California Code of Regulations , Title 23 , Division <br /> 3 , Chapter 16, Section 2637 and all the information <br /> contained herein is accurate. <br /> UST Service Technician Signature t%�zGi?r .J' el/ur�,►2c�v <br /> FE3 0 5 2019 <br /> I CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- <br /> Dispenser Containment <br /> i <br />