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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 [:136 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10184805 10/9/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Food 4 Less Business Site Address City ZIP Code 610 Cherokee Ln. 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# Eusebio Sousa (707)545-5522 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date Able Maintenance, Inc. -312844 5254516 7/12/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID:(By tank number,stored product,etc.) A 87 B 91 C D Tank Containment Tightness Test Result ❑Pass ❑Fail m NA ❑Pass ❑ Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Product Piping Containment Tightness Test Result m Pass ❑Fail ❑NA m Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail m NA ❑Pass ❑ Fail m NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Vent Piping Containment Tightness Test Result ❑Pass ❑ Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑ Fail 0 NA ❑Pass ❑ Fail m NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result m Pass ❑Fail ❑NA m Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Turbine/Product Piping Sump Tightness Test Result ❑Pass Cl Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Fill Riser Sump Tightness Test Result ❑Pass ❑Fail m NA ❑Pass Cl Fail ®NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA UDC ID: 1 UDC 1/2 2 UDC 3/4 3 UDC 5/6 4 Tightness Test Result m Pass ❑Fail ❑NA 0 Pass ❑Fail ❑NA m 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 ❑ Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA All items marked"Fail'or"NA"must be explained in their respective"COMMENTS"secti ,, h IV. CERTIFICATION BY UST SERVICE TECHNICIAN C G tWiln I hereby certify that the secondary containment was tested in accordance with C lif o la ons; it a 3,Division 3,Chapter 16,Section 2637 and all the information contained herein is accurate. UST Service Technician Signature AA N CERS=Califomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank ICC WPPcTtW UDC=Under- Dispenser Containment n F PA AT nA F NIT