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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 ❑x 36 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10182207 1 9/9/2019 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Flag City Shell <br /> Business Site Address City ZIP Code <br /> 6437 West Banner Street Lodi 95242 <br /> II . 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 -a-test/90 - 1120 524680MT 3/20/2021 <br /> III . 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 E 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 ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA <br /> Turbine / Product Piping Sump <br /> Tightness Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> VENT / TRANSITION SUMP ID : a b C d <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 1 1 &2 2 3&4 3 5&6 4 7&8 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA <br /> UDC ID : 5 9& 10 6 11 & 12 7 13& 14 8 15& 16 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E 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 CONDIfTil` G HIS TSS t I'NG F <br /> I hereby certify that the secondary containment was tested in accordance with California dbde7of`kgdblati,4r s , Trtle123,' Division <br /> 3 , Chapter 16, Section 2637 and all the information contained herein is accurate . <br /> UST Service Technician Signature <br /> CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemq!OAT l od,G4uI :N pt App icable UDC = Under- <br /> Dispenser Containment t $ " I e €' ` ''ff g I ° (» € I <br />€h <br /> t <br />