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=NVIF 77 71 77 UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Fype Action ❑ Installation Test ® Repair Test ❑ Six Month Test ❑ 36 Month Test I. FACILITY INFORMATION CERS ID 10181229 Date of Secondary Containment Test 12/12/2020 Business Name (Same as Facility Name or DBA -Doing Business As) Speedway 4873 Business Site Address 35 N. Cherokee Ln. City Lodi ZIP Code 95240 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Eusebio Sousa Phone # (707) 545-5522 Contractor / Tank Tester License # Able Maintenance, Inc. - 312844 ICC Certification # 5454516 ICC Certification Expiration Date 7/12/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product, etc.) A B C D Tank Containment Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail la NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result ❑ Pass ❑ Fail la NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result VENT I TRANSITION SUMP ID: ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA a b ❑ Pass ❑ Fail ❑ NA C ❑ Pass ❑ Fail ❑ NA d Tightness Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID: 13/4 2 3 4 Tightness Test Result m Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID: 5 6 7 8 Tightness Test Result UDC ID: ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA 9 10 ❑ Pass ❑ Fail ❑ NA 11 ❑ Pass ❑ Fail ❑ NA 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 CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under - Dispenser Containment