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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 N 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10184311 11125119 Business Name (Same as Facility Name or DBA-Doing Business As) United Pacific #5449 Business Site Address City ZIP Code 322 South Center Street Stockton , Ca . 95203 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification.) Phone # Richard Thomas ( 916 ) 991 - 1100 Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date CSLB#803616 SWRB#06 -1672 5254736 11 /03/2020 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID : (By tank number, stored product, etc.) T-1 87 T-2 91 Tank Containment Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass E01 Fail ElNA ElPass ElFail ElNA Communication Test Result N Pass E] Fail ❑ NA N Pass E] Fail E] NA ElPass E] Fail ❑ NA E] Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result El Pass ElFail N NA ElPass E] Fail N NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vent / Transition Sump ID : Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail N NA UDC ID : #1 -2 #34 #5-6 #7-8 Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA UDC ID : #9 -10 #11 -12 Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : Tightness Test Result ❑ Pass ❑ Fail ❑ NA JE1 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA All items marked "Fail' or "N/A " must be explained in their respective "COMMENTS " section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDO TI SSI G I hereby certify that the secondary containment was tested in accordance with California Code of R g Inti ;ns t e 23, division 3 , chapter 16 , section 2637 and all the information contained herein is accurate. UST Service Technician Signature iF I ` i � P ! +t�C _. hi ..E. CERS = California Environmental Reporting System, ID = Identification , UST = Underground storage tank, ICC = International Code Council, NA = Not applicable, UDC = Under-dispenser containment