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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 ❑x 36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10156811 9/18/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Safeway 2707 Business Site Address City ZIP Code 6425 N Pacific Ave Stockton 95207 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# Mauricio Miranda (925) 671-9200 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date 256896 8407460 12/27/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number,stored product,etc.) A T1-87 B T2-91 C T3-Diesel D Tank Containment Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result p Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail El NA ❑ Pass ❑ Fail ❑NA Vent Piping Containment Tightness Test Result El Pass ❑ Fail ❑ NA El Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA Communication Test Result El Pass ❑ Fail ❑ NA El Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA Communication Test Result O Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA Turbine/Product Piping Sump Tightness Test Result O Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA Fill Riser Sump Tightness Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA VENT/TRANSITION SUMP ID: a Vent Box b C d Tightness Test Result O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail [0:1NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA UDC ID: 1 Disp 1-2 2 Disp 3-4 3 Disp 5-6 _K Disp 7-8 Tightness Test Result O Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑NA El Pass ❑ Fail ❑NA UDC ID: 5 Disp 9-10 6 Disp 11-12 7 Disp 13-14 8 Disp 15-16 Tightness Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA p Pass ❑ Fail ❑NA p Pass ❑ Fail ❑NA UDC ID: 9 10 11 112 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA I ❑ 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 v7��IU0 r a IPZ4 CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- Dispenser Containment