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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 ❑x 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10180913 9/ 16/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Ernie's General Store Business Site Address City ZIP Code 4407 East Waterloo Road Stockton 195215 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Benjamin Duncan ( 707 ) 621 -0378 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date Tank Tester License #90- 1120 5246802- UT 3/21 /2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) A T- 1 - Regular 87 B T-2-Super 91 C T-3-Diesel D Tank Containment Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 1 &2-RT 2 3&4-RT 3 5&6-RT 4 7&8-13T Tightness Test Result E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA UDC ID : 5 9& 10-RT 6 1 &2-CL II 7 3&4-CL 8 5&6-CL Tightness Test Result Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA 1 E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA UDC ID : 9 7&8-CL 10 9& 10-CL 11 12 Tightness Test Result E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA All items marked "Fail" or "NA " must be explained in their respective "COMMENTS" section. N. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTII`tgj" S,T I NG I hereby certify that the secondary containment was tested in accordance with Californ egyiaoC' v' on 3 , Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council NA = Not Applicable UDC nder- Dispenser Containment ENVIRON 1k� � . N"EAl i i � a � a�.