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W . O . # NW1 - 2339733 UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test El 36 Month Test i. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10166021 12-21 -18 Business Name (Same as Facility Name or DBA-Doing Business As) 7- 11 Business Site Address City ZIP Code 2360 w, grantline trnr 95356 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # jarrod Cooke (209)321 - 2724 Ext. Contractor/Tank Tester license # ICC Certification # ICC Certification Expiration Date 743160 8155550 4-6-19 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID: (By tank number, stored product, etc.) A reg B Sup C mul D Tank Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ® Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA Communication Test Result (0 Pass ❑ Fail ❑ NA I] Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA ® Pass El Tail [INA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fait ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result REIFa Fail ❑ NA ❑ Pass [:] Fall ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vent I Transition Sump ID: b C d Tightness Test Result Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Faii ❑ NAuDCID: 23/4 35/6 7/8 Tightness Test Result ail ❑ NA ® Pass ❑ Fail ❑ NA ID Pass ❑ Fail ❑ NA E) Pass ❑ Fail ❑ NA UDC ID: 611 /12 7 8 Tightness Test Result ail ❑ NA ® Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA uDc lo: 10 11 12 Tightness Test Result ❑ Pass ❑ Fail ❑ NA 10 Pass ❑ Fall ❑ NA ID Pass ❑ Fail ❑ NA 111 Pass ❑ Fail ❑ NA All items marked "Fail' or "N/A " must be explained In their respective "COMMENTS" section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the secondary containment was tested in accordance with Califomia Code of Regulations, title 23, division 3, chapter 16, section 2637 and all the information contained herein is accurate. UST Service Technician Signature CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, NA = Not applicable, UDC = Under-dispenser containment AN 0 9 2019 A L - t