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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (page t 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 /> 10181391 1 10/14/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> St. Joseph's Medical Center <br /> Business Site Address City ZIP Code <br /> 1800 North California Street Stockton 95204 <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-test190-1120 5246802-UT 3/23/2021 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID:(By tank number,stored product,etc.) A T-1-Fuel Oil B C D <br /> Tank Containment <br /> Tightness Test Result ❑Pass ❑Fail M NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Product Piping Containment <br /> Tightness Test Result El Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail El NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail El NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail p NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail p NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail El NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail p NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail p NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Turbine/Product Piping Sump <br /> Tightness Test Result p Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑Pass ❑Fail El NA ❑Pass []Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> VENT 1 TRANSITION SUMP ID: a b c d <br /> Tightness Test Result ❑Pass ❑ Fail El NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> UDC ID: 1 2 3 4 <br /> Tightness Test Result ❑Pass ❑Fail El NA ❑Pass ❑Fail I]NA ❑Pass ❑Fail CI NA ❑Pass ❑Fail p NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Result ❑Pass ❑Fail El NA ❑Pass ❑Fail CI NA ❑Pass ❑Fail p NA ❑Pass ❑Fail p NA <br /> UDC ID: $ 10 11 12 <br /> Tightness Test Result ❑Pass ❑Fail El NA ❑Pass ❑Fail I7 NA ❑Pass ❑Fail 0 NA ❑Pass ❑Fail p NA <br /> All items marked"Fall"or"NA"must he explained in their respective"COMMEWS"section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations,Title 23,Division <br /> 3,Chapter 76,Section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> CERS=Carifomia Environmental Reporting System,ID=Identification,UST=Underground Storage Tank ICC=International Code Council,NA=Not Applicable.UDC=Under- <br /> Dispenser Containment <br />