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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑ Installation Test ❑ Repair Test Six Month Test ❑ 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10181559 1 4/24/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Kaiser Manteca Business Site Address City ZIP Code 1777 W Yosemite Ave Manteca 195337 Il . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Saul Gonzalez 949460-5200 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 808313 - Class A 5254881 9/ 19/2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) A Diesel B C D Tank Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fair [INA ❑ Pass El Fail [INA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑ Pass [] Fail ❑ NA (:] Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail [INA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass I❑ Fall ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result [:] Pass ❑ Fail ❑ NA (:] Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass [:] Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail [INA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail [INA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass I❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass I❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result Pass ❑ Fail ❑ NA ❑ Pass [] Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail ❑ NA [] Pass ❑ Fail ❑ NA ❑ Pass I❑ Fail ❑ NA [:] Pass ❑ Fail [INA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail ❑ NA [:] Pass ❑ Fail ❑ NA ❑ Pass I❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 2 3 4 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass El Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 5 11 6 7 8 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass C] 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 Q NA All items marked "Fail" or "NA " must be explained in their respective "COMMENTS " section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING 1 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 , _ r CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- Dispenser Containment