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01 <br />I <br />UNDERGROUND STORAGE TANK <br />SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) I <br />Type of Action 0 Installation Test 0 Repair Test D Six Month Test El 36 Month Test <br />I. FACILITY INFORMATION <br />CERS ID Date of Secondary Containment Test <br />11/08/2018 <br />Business Name (Same as Facility Name or DBA -Doing Business As) <br />Unified Grocers, Inc. <br />Business Site Address <br />1990 Piccoli Rd. <br />City <br />Stockton <br />ZIP Code <br />95215 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) <br />Jarrett Flewellyn <br />Phone # <br />(714) 560-8222 <br />Contractor / Tank Tester License # <br />588098 <br />ICC Certification # <br />8028164 <br />ICC Certification Expiration Date <br />03-29-2019 <br />III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br />TANK ID: (By tank number, stored product, etc.) A Diesel <br />. <br />B T-2 C T-3 D T-4 <br />Tank Containment . <br />Tightness Test Result LI Pass 0 Fail 111 NA l=1 Pass 0 Fail 0 NA <br />. _ . <br />0 Pass El Fail 0 NA D Pass 0 Fail Li NA <br />Product Piping Containment . . .. , _ . ••,--,4k . ! • ,i1,:,,,..i...... —14, <br />Tightness Test Result E Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA D Pass 0 Fail I: NA <br />Communication Test Result 0 Pass 0 Fail ILI NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail ID NA <br />Remote FM Piping Containment ' .:., ialrietal. .. Ilierial Mar, r <br />Tightness Test Result 0 Pass 0 Fail E NA III Pass 0 Fail 0 NA ID Pass 0 Fail ED NA 0 Pass 0 Fail Ill NA <br />Communication Test Result 0 Pass D Fail 0 NA 0 Pass 0 Fail CI NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Vent Piping Containment . . ATM PIti, :r 2' 1 if•SIOLINEgr <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA D Pass 0 Fail 0 NA <br />Communication Test Result 0 Pass 0 Fail g NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fall 0 NA 0 Pass D Fail 0 NA <br />Vapor Recovery Piping Containment <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fall 0 NA li] Pass 0 Fail E NA 0 Pass 0 Fail 0 NA <br />Communication Test Result D Pass 0 Fail E NA 0 Pass 0 Fail 0 NA El Pass ill Fail []NA 0 Pass 0 Fail D NA <br />Turbine! Product Piping Sump , ' • ,',; , ,-_--. <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Fill Riser Sump .'7.":r7:n' , • 1 _ <br />Tightness Test Result 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA , 0 Pass D Fail 0 NA 0 Pass 0 Fail 0 NA 1 <br />VENT / TRANSITION SUMP ID: a b c d <br />Tightness Test Result - 0 Pass CI Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fall 0 NA <br />UDC ID: 1 Diesel 2 3 4 1 <br />Tightness Test Result ID Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fall 0 NA <br />UDC ID: 5 6 7 8 <br />Tightness Test Result lil Pass D Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail ID NA <br />UDC ID: 9 '10 11 12 <br />Tightness Test Result ID Pass 0 Fail 0 NA 0 Pass 0 Fall 0 NA 0 Pass ID Fail El NA 0 Pass 0 Fail 0 NA <br />All items marked "Fail" or "NA" must be explained In their respective "COMMENTS" section. <br />IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br />I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, Title 23, Division <br />3, Chapter 16, Section 2637 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />pavrete 7eeivee4o <br />CERS = California Environmental Reporting System, ID" Identification, UST= Underground Storage Tank, ICC = International Code Council, NA= Not Applicable, UDC = Under- <br />Dispenser Containment