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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Pagel of 6) Type of Action ❑Installation Test ❑Repair Test Eil 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 195207 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC 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 O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA El Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑NA O Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA El Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑Fail E NA ❑Pass ❑Fail O NA ❑Pass ❑Fail O NA ❑Pass ❑Fail ❑NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑Fail O NA ❑Pass ❑Fail p NA ❑Pass ❑Fail ❑NA Vent Piping Containment Tightness Test Result O Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result O Pass ❑Fail ❑ NA E Pass ❑ Fail ❑NA O Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result E Pass ❑Fail ❑ NA p Pass ❑Fail ❑NA E Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result O Pass ❑Fail ❑ NA O Pass ❑Fail ❑NA p Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Turbine/Product Piping Sump Tightness Test Result p Pass ❑ Fail ❑NA E Pass ❑ Fail ❑ NA El Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA Fill Riser Sump Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a Vent Box b C d Tightness Test Result E Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA UDC ID: 1 Disp 1-2 2 Disp 3-4 3 Disp 5-6 4 Disp 7-8 Tightness Test Result E Pass ❑ Fail ❑NA E Pass ❑Fail ❑NA E Pass ❑Fail ❑ NA O Pass ❑Fail ❑NA UDC ID: 5 Disp 9-10 6 Disp 11-12 7 Disp 13-14 8 Disp 15-16 Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑ Fail ❑ NA O Pass ❑Fail ❑NA E 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 THISZESTING I hereby certify that the secondary containment was tested in accordance with California Code of RegulationsT�tl vision 3,Chapter 16,Section 2637 and all the information contained herein is accurate. i U 1 UST Service Technician Signature / a"-b a �-IP& ENVIRON1 , I CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable.UDC=Under- Dispenser Containment