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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 /> 10180657 7/13/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Synergy-Hunter-Stockton Mobil 1 <br /> Business Site Address City ZIP Code <br /> 642 North Hunter Street Stockton 95202 <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# Certification# ICC Certification Expiration Date <br /> ICC <br /> Tank Tester License #90-1120 5246802-UT 3/21/2021 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID: (By tank number,stored product,etc.) A T-1-Super 91 B T-2-Regular 87 C T-3-Regular 87 D T-4-Diesel <br /> Tank Containment <br /> Tightness Test Result E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result O Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA <br /> Communication Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑ NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail M NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail I] NA ❑ Pass ❑ Fail I] NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> Vent Piping Containment <br /> Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA Z Pass ❑ Fail ❑NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑NA ❑ Pass ❑ Fail E NA <br /> Communication Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA ❑ Pass ❑ Fail E NA <br /> Turbine/Product Piping Sump <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA Z 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 E NA <br /> VENT/TRANSITION SUMP ID: a b C d <br /> Tightness Test Result <br /> El Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ENA <br /> UDC ID: 1 10 2 2&4 3 5&7 4 6&8 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA Z Pass ❑ Fail ❑NA <br /> UDC ID: 5 9&11 6 10&12 7 8 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA E Pass OF il ❑ NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> UDC ID: 9 10 1112 <br /> Tightness Test Result <br /> El El Fail [:1 NA El Pass El Fail [:1 NA El Pass El Fail <br /> ❑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 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 16, Section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- <br /> Dispenser Containment <br />