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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑ Installation Test ❑ Repair Test ❑x Six Month Test ❑36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10184349 9/18/2020 Business Name(Same as Facility Name or DBA-Doing Business As) Pilot Flying J #617 Business Site Address City ZIP Code 15237 N Thornton Lodi 95242 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# Jose Ochoa (888) 972-7581 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 804431 A,B HAZ 8004551-UT 10/28/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number,stored product, etc.) A T-1 B T-2 C T-3 D T-4 Tank Containment Tightness Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Product Piping Containment Tightness Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Communication Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail EINA ❑Pass ❑Fail EINA ❑Pass ❑Fail ENA ❑Pass ❑Fail ZNA Communication Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Vent Piping Containment Tightness Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Communication Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Communication Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA ❑Pass ❑Fail ENA Turbine/Product Piping Sump Tightness Test Result ❑Pass ❑Fail ENA ZPass ❑Fail DNA EPass ❑Fail DNA ZPass ❑Fail DNA Fill Riser Sump Tightness Test Result EPass ❑Fail DNA ZPass ❑Fail ❑NA EPass ❑Fail DNA EPass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail ENA ❑Pass ❑Fail [ENA ❑Pass ❑Fail EINA ❑Pass ❑Fail ZNA UDC ID: 1 7-8 2 13 3 16-17 4 Tightness Test Result EPass ❑Fail ❑NA EPass ❑Fail DNA EPass ❑Fail DNA ❑Pass ❑Fail DNA UDC ID: 5 6 7 8 Tightness Test Result ❑Pass ❑Fail DNA ❑Pass ❑Fail DNA ❑Pass ❑Fail DNA ❑Pass ❑Fail DNA UDC ID: J 10 11 12 Tightness Test Result ❑Pass ED]Fail DNA ❑Pass ❑Fail DNA ❑Pass ❑Fail DNA [:]Pass ❑Fail DNA All items marked"Fail"or"NA"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 California Code of Regulations,Title 23,Division 3, Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature r CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- Dispenser Containment