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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 10181355 1 7/ 17/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Tiwana Gas and Food Business Site Address City ZIP Code 1210 East Hammer Lane Stockton 95210 Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification) Phone # Benjamin Duncan ( 707 ) 621 - 0378 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date Tank Tester License #90 - 1120 524680MT 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- Diesel C T-3 -Super 91 D Tank Containment Tightness Test Result El Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA EI Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result p Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail EI NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail EI NA ❑ Pass ❑ Fail El NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail El NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result O Pass ❑ Fail ❑ NA EI Pass ❑ Fail ❑ NA El Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 1 &2 2 3&4 3 5&6 4 7&8 Tightness Test Result El Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑ NA EI Pass ❑ Fail ❑ NA ® Pass ❑ Fail ❑ NA I 11 UDC ID : 5 6 7 18 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 9 10 11 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 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 UVEI JJ '' CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, [CC = International Code Council, NA =JrudW61iclbla( = Under- Dispenser Containment ` NVMCMENTAL HEALTH