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UNDERGROUNDSTORAGETANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action installation Test Repair Test Six Month Test 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test: <br /> 10166191 8/5/2020 <br /> Business Name ( Same as Facility Name or DBA- Doing Business As) <br /> 7 ELEVEN 35355 <br /> Business Site Address City: Zip: <br /> 3202 W HAMMER LANE (W136) STOCKTON 95209 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification . ) Phone # <br /> Jarrod Cooke (800 ) 800-4633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 5311523-UT 4/3/2021 <br /> 111. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> Tank ID: (By tank number, stored product, etc) T1 : T2 : T3 : Diesel <br /> Tank Containment <br /> Tightness Test Result W Passr Failr NA F Passr Failr NA W Passr Failr NA r Passr Fail[' NA <br /> Product Piping Containment <br /> Tightness Test Result V Pass [' Fail [' NA r PassF Failr NA F Passr Failr NA r PassF Failr NA <br /> Communication Test Result r Passr Failr NA r Pass [' Failr NA r Passr Fail[' NA r Passr Fair NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result r Passr Fair NA r Passr Fair NA r Pass[' Fair NA r Passr Fair NA <br /> Communication Test Result r Passr Fair NA [' PassF Fair NA r Pass[' Fair NA r Passr Fair NA <br /> Vent Piping Containment <br /> Tightness Test Result r Passr Fair NA r Passr Fair NA r Passr Fair NA r Passr Fair NA <br /> Communication Test Result r Pass [' Fair NA r Pass [' Fair NA r Pass[' Fair NA r Passr Failr NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result r Passr Failr NA r Passr Fail [' NA r Passr Failr NA r Passr Failr NA <br /> Communication Test Result r Pass [' Failr NA r Passr Fail [' NA r Passr Fair NA r Passr Failr NA <br /> Turbine / Product Piping Sump <br /> Tightness Test Result V Passr Fall [' NA P' Passr Failr NA V' PassF Fair NA r Passr Fair NA <br /> Fill Riser Sump <br /> Tightness Test Result r Passr Failr NA r Passr Fail [' NA r PassF Fall[' NA r Passr Failr NA <br /> Vent / Transition Sump ID : a b c d <br /> Tightness Test Result r Passr Failr NA r Passr Failr NA r Passr Failr NA r Passr Failr NA <br /> UDC ID: 1 1 /2 2 3/4 3 5/6 4 7/8 <br /> Tightness Test Result W Passr Failr NA V PassF Failr NA R Passr Failr NA F Passr Failr NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Result r Passr Failr NA r Passr Failr NA r PassF Failr NA r Passr Failr NA <br /> UDC ID: 9 10 11 12 <br /> Tightness Test Result r Pass [' Failr NA r Passr Failr NA r Passr Failr NA r Passr Failr NA <br /> All items marked "Fail" or "N/A " must be explained in their respective "COMMENTS " section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations , title 23 , division 3 , chapter 16, <br /> section 2637. 1 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 , <br /> NA = Not applicable , UDC = Under-dispenser containment <br />