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01 <br />UNDERGROUND STORAGE TANK <br />SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 01 6) <br />Type of Action 11 Installation Test 1:1 Repair Test CI Six Month Test 36 Month Test 111 <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 B T-2 C T-3 D T-4 <br />Tank Containment <br />Tightness Test Result D Pass 0 Fail D NA El Pass 0 Fail El NA El Pass 0 Fail El NA 0 Pass 0 Fail 0 NA <br />Product Piping Containment <br />Tightness Test Result 0 Pass ID Fail El NA 0 Pass 0 Fail 0 NA CI l)ass El Fail 111 NA 0 Pass 0 Fail El NA <br />Communication Test Result 0 Pass El Fail E NA 0 Pass 0 Fail El NA H Pass 0 Fail 0 NA 111 Pass El Fail El NA <br />Remote Fill Piping Containment , <br />Tightness Test Result 0 Pass [I Fail lEl NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass D Fail 0 NA <br />Communication Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail D NA <br />, <br />0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Vent Piping Containment <br />Tightness Test Result El Pass El Fail D NA El Pass 0 Fail ID NA 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA <br />Communication Test Result 0 Pass 0 Fail 0 NA El Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Vapor Recovery Piping Containment --;V-, - .- — - " • . <br />Tightness Test Result 0 Pass 0 Fail 0 NA DPass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Communication Test Result El Pass 0 Fail E NA ID Pass El Fail 0 NA El Pass 0 Fail 0 NA Ill Pass E] Fail C] NA <br />Turbine! Product Piping Sump <br />Tightness Test Result Ni Pass D Fail 0 NA 0 Pass [I Fail El NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail DI NA <br />Fill Riser Sump . <br />Tightness Test Result D Pass D Fail 0 NA El Pass El Fail El NA El Pass 0 Fail 0 NA 0 Pass El Fail 0 NA <br />VENT/TRANSITION SUMP ID: a b c d <br />Tightness Test Result El Pass Li Fail 0 NA 0 Pass 0 Fail 0 NA 111 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />UDC ID: 1 Diesel 2 3 4 <br />Tightness Test Result 0 Pass D Fail 0 NA El Pass D Fail 0 NA 0 Pass ID Fail 0 NA 0 Pass li] Fail El NA <br />UDC ID: 5 6 7 8 <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail Li NA 0 Pass 0 Fail 0 NA 0 Pass IA Fail 0 NA <br />UDC ID: 9 10 11 12 <br />Tightness Test Result El Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail ID 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 />paNteet 9tewet44t <br />CERS = California Environmental Reporting System, ID = Identification, UST= Underground Storage Tank, ICC = International Code Council, NA= Not Applicable, UDC = Under <br />Dispenser Containment