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01 <br />I <br />UNDERGROUND STORAGE TANK <br />SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br />N Repair Test n Six Month Test 36 Month Test Type of Action • Installation Test II <br />I. FACILITY INFORMATION <br />CERS ID <br />10181455 <br />Date of Secondary Containment Test <br />12/23/2019 <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 />Craig Feezell <br />Phone # <br />(209) 643-9747 <br />Contractor! Tank Tester License # <br />588098 <br />ICC Certification # <br />8374133 <br />ICC Certification Expiration Date <br />7/3/2021 <br />III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br />TANK ID: (By tank number, stored product, etc.) A T-1 Diesel B 1-2 C T-3 D T-4 <br />Tank Containment <br />Tightness Test Result 0 Pass 0 Fail D NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass LI Fail 0 NA <br />Product Piping Containment <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Communication Test Result 0 Pass 0 Fail 0 NA 0 Pass D Fail 0 NA 0 Pass 0 Fail 0 NA CI Pass CI Fail CI NA <br />Remote Fill Piping Containment <br />Tightness Test Result 0 Pass LI Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA Iii Pass 0 Fail 0 NA <br />Communication Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA E Pass E Fail u NA <br />Vent Piping Containment <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass E Fail 0 NA 0 Pass 0 Fail 0 NA <br />Communication Test Result 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA E Pass 0 Fail 0 NA 0 Pass 0 Fail E NA <br />Vapor Recovery Piping Containment <br />Tightness Test Result 0 Pass 0 Fall 0 NA 0 Pass 0 Fail 0 NA CI Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Communication 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 />Turbine! Product Piping Sump i <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 <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA CI Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />VENT / TRANSITION SUMP ID: a b c d <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 />UDC ID: 1 2 3 4 <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 />UDC ID: 5 6 7 8 <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 />UDC ID: 9 10 11 12 <br />Tightness Test Result 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass El 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 /> A 7s4' U Check If Action Item(s) Are Present <br />CERS = California Environmental Reporting System, ID = Identification, UST= Underground Storage Tank, ICC = International Code Council, NA= Not Applicable, UDC = Under- <br />Dispenser Containment