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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 ❑ 36 Month Test <br /> 1 . FACILITY INFORMATION <br /> CERS ID T Date of Secondary Containment Test <br /> 10184829 111 /8/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Food 4 Less <br /> Business Site AddressCity ZIP Code <br /> 1427 S . Airport Way Stockton 95206 <br /> Ila UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # <br /> Eusebio Sousa (707) 545-5522 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Able Maintenance , Inc. - 312844 5254516-UT 7/12/2021 <br /> III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID : (By tank number, stored product, etc.) A B C D <br /> Tank Containment <br /> Tightness Test Result ❑ Pass ❑ Fail 21 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fall ❑ NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA [] Pass ❑ Fail ❑ NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Turbine / Product Piping Sump <br /> Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fair ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> VENT / TRANSITION SUMP ID: a b c d <br /> Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 1 UDC 1 /2 2 UDC 3/4 3 4 <br /> Tightness Test Result m Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 5 6 7 8 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 9 10 11 12 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> All items marked "Fail' or "NA " must be explained in their respective "COMMENTS" section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CON N <br /> hereby certify that the secondary containment was tested in accordance with Calif _ ni v_ , 'Ilpf,Re o , ision <br /> 3, Chapter 16, Section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature N ( ) V <br /> CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Inte��tippI )� ?up il,)tVA= of 6 1 � = Under- <br /> DispenserContainmerrt C ' l i iVi �) i 6 i fi <br /> D !` PAr I' lM NT <br />