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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page I of 6) Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test ❑x 36 Month Test I. FACILITY INFORMATION CERS ID 10181469 Date of Secondary Containment Test 1 6/9/2020 Business Name (Same as Facility Name or DBA-Doing Business As) SMK Chevron Business Site Address 25651 North Hwy 99 City Acam o ZIP Code 95220 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Benjamin Duncan Phone # (707) 621-0378 Contractor i Tank Tester License # Tank Tester License #90-1120 ICC Certification # 5246802-UT ICC Certification Expiration Date 3/21/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product, etc.) A T-1-Diesel B T-2-Supreme 91 C T-3-Regular D Tank Containment Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Turbine 1 Product Piping Sump Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E 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 I TRANSITION SUMP ID: a b C d Tightness Test Result ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA UDC ID: 1 1&2 2 3&4 3 5&6 4 7&8 Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA UDC ID: 5 9&10 6 11&12 7 8 Tightness Test Result E Pass ❑ Fail ❑ NA E 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 CON DUCT112M rfqff, I hereby certify that the secondary containment was tested in accordance with California C . ee lath le, n 3, Chapter 16, Section 2637 and all the information contained herein is accurate. f UST Service Technician Signature JUN � 4 2020 CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = InternationalCouncil, NA= Not Applicable, UDC = Under - Dispenser containment /IRONMENTAL HEALTH DEPARTMENT