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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 0 36 Month Test I. FACILITY INFORMATION CERS ID 10181231 Date of Secondary Containment Test 112/12/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Speedway #68152 Business Site Address 401 W. Kettleman Ln. City Lodi ZIP Code 95240 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Michael McCarter Phone # (707) 545-5522 Contractor / Tank Tester License # Able Maintenance, Inc. - 312844 ICC Certification # 8819839 ICC Certification Expiration Date 10/15/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product, etc.) A 87 B 91 C D Tank Containment Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass Cl Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result VENT / TRANSITION SUMP ID: ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA a b ❑ Pass ❑ Fail ❑ NA C ❑ Pass ❑ Fail ❑ NA d Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID: 11/2 23/4 35/6 47/8 Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA UDC ID: 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID: 9 10 111 12 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA All items marked "Fail" or "NA" must be explained in their respective "COMMENTS" section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CON G_,Ti4S:,TESTINC..-. x: I hereby certify that the secondary containment was tested in accordance with Calif ,d 3, Chapter 16, Section 2637 and all the information contained herein is accurate. ededof Rdgufaoogs; a 2,, , D ision UST Service Technician Signature _. CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Canal, NA = Not Applicable, UDC = Under - Dispenser Containment ENVIRONMENTAL HEALTH DEPARTMENT