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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 ® 36 Month Test 1 . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10184805 8/16/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Food 4 Less Business Site Address City ZIP Code 610 Cherokee Ln . I 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 # Michael McCarter (707) 545-5522 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date Able Maintenance , Inc. - 312844 8819839 10/25/2019 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 ❑ NA ® Pass ❑ Fall ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑ Pass 0 Fail ❑ NA ❑ Pass m Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail la NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA i Vent Piping Containment i Tightness Test Result m Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA j Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass [] Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass 0 Fail ❑ NA ❑ Pass ® Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result ® Pass ❑ Fail ❑ NA la Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA E Fill Riser Sump Tightness Test Result m Pass ❑ Fail ❑ NA ® Pass ❑ 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 ® NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 11 /2 23/4 35/6 4 Tightness Test Result ❑ Pass m Fail ❑ NA ❑ Pass ® Fail ❑ NA ❑ Pass m 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 " section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDO STING Fr I hereby certify that the secondary containment was tested in accordance with Californiae�of Rejf6lations , title 24„[3 y00Ion 3 , Chapter 16 , Section 2637 and all the information contained herein is accurate. UST Service Technician Signature l 1 CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = IntemaprR U t i I pl ttlA ( fit Appli ble QDCg $ = Under- Dispenser Containment