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Mar , 9 , 2020 11 , 11AM Donlee Pump Co No , 3522._ P , 2
<br /> UNDERGROUND STORAGE TANK
<br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page I of 6)
<br /> Type of Action ❑ Installation TestPIN
<br /> air Test L1Six Month Test p 36 Month Test
<br /> 1, FACILITY INFORMATION
<br /> CERS ID Date of Secondary Containment Test
<br /> 3/5/2020
<br /> Business Name (Same as Facility Name or DBA-Doing Business As)
<br /> ER Vine and Sons - Stockton
<br /> Business Site Address city ZIP Code
<br /> 4733 S . Hwy 99 Frontage Rd Stockton 615 R 0C
<br /> IL UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION
<br /> Name of UST Service Technician Performing the Test (Print as shown on the ICG Cerfrfrcatlon,) Phone #
<br /> Alex Brand (209) 537 - 9396 Ext-
<br /> Contractor/ Tank Tester l.lmnse # ICC Certification # ICC Certification Expiration Date
<br /> 8881772 5/2021
<br /> 111 . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS
<br /> Tank ID : (ey tank number, stored product, etc,) A E C D
<br /> "r."N. 'r:F=v:•:'gri '1F'r?cE? f , o _ -... .. . n::; ;n:�)) c _ -__
<br /> .J ;a��^?� c!.....�,. •l ::vEi' ' rs:a.�iii '.vl, �,h-_
<br /> Tank Containment ::a 7a :::::: n ? :;ft, = v : : :r� l ,rT ""1 rc ' ;" °::: !1 _ >: .
<br /> Tightness Test Result d Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fait ❑ NA
<br /> __tai .a__ a - -� ---* ri } F
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<br /> Product Piping Containment :.�: ( ham:=_ ». Ysz11:: z d, =sxa: '€ - ti=t +Tt:-_-'s, ;l` `_s . :,::: s � t4 rr ,:: =u ,
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<br /> Tightness Test Result ❑ Pass ❑ Fail Q NA ❑ Pass Ij Fail ❑ NA ❑ Pass © Fail d NA ❑ Pass ❑ Fail [j NA
<br /> Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fall ❑ NA
<br /> 0114W - a t Ed
<br /> Lp
<br /> Remote Fill Piping Containment M-:�r = •' :n- Ed
<br /> = , :-. , . .;1•r.-_,,: . �> 71711 „ 0140" 1946, n§ si r°4. .
<br /> Tightness Test Result ❑ pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Cl Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA
<br /> Communication Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA
<br /> P Edv i _ Vi e, c y � "-:� 'M _ _ =:.,,f
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<br /> Vent Piping Containment J J! ...v :: gi _ 5? .
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<br /> Tightness Test Result El Pass ❑ Fail ❑ NA U Pass ❑ Fall ❑ NA ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fall ❑ NA
<br /> Communication Test Result [.1 Pass ❑ Fall ❑ NA ❑ Pass ❑ Feil 1] NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fall ❑ NA
<br /> x ! , . . -;: : { : -_`u ` ? ,,: . hs__. ;}, _v, :-=:•:
<br /> ' < -'aVapor RecoveryPiping Containment Ed
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<br /> VIA, -
<br /> Tightness Test Result ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail d NA
<br /> Ed
<br /> Commtnnlcalion Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass Q Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA
<br /> �t - _ » _•
<br /> :r. ,-:.:cre ...aF: j _c1� r r _s i r u �..�� 4?x �-'?c s� 'E:g�{ _ - :ani _ ,.r Egg Ed �•:_?''c:_':s.9
<br /> Turbine 1 Product Piping Sump , ':r� - . ,, Y`: '• �- iN tt t== v tti =: , „ !' ata-: . . _: r�Y
<br /> Tightness Test Result Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ rail ❑ NA ❑ Pass ❑ Fail ❑ NA
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<br /> "."..._Je: Yri•_'-:^�!9x.• P(��u. l-e„' _•..: . �7 -•'e :.. ii-sxtizdd
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<br /> a€t __a
<br /> Fill h ;r'tsar Sum
<br /> r.i .........
<br /> Tightness Test Result ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fail IJ NA 0 Pass ❑ Fall JLJNNAElPass ElFall ❑ NA
<br /> Vent l Transition Sump ID : a b C d
<br /> Tightness Test Re-suita Pass ElFail C1NA ❑ Pass [IFall EINA [IPass ElFail ❑ Pass ❑ Fall ❑ NA
<br /> UDC ID ; 1 2 3 4
<br /> Tightness Test Result ❑ Pass ❑ Fall ❑ NA ❑ Mass ❑ Fail 1J NA ❑ Pass ❑ Fail Q NA ❑ Pass ❑ Fall ❑ NA
<br /> UDC ID . 5 16 7 8
<br /> Tightness Test Result Q Pass ❑ Fail ❑ NA ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fail ❑ NA
<br /> UDC ID: 9 10 11 12
<br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA El Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA
<br /> All items marked "Fall' or "N/A" must be explained in their respective "COMMENTS" sectional"
<br /> IV, CERTIFICATION BY UST SERVICE TECHNICIAN CONWCTING THIS TES1' INC
<br /> I hereby certify that the secondary containment was tested in accordance with California 666 di Regull Ions, title 231
<br /> EELdivision 3 , chapter 16, section 2837 and all the information contained herein Is accurate,
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<br /> UST ry T n S
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<br /> Ed E4
<br /> CEIRS = California Environmeniai Reporting System, JIU = Identitltation, UST = 'U•nder#round storage tank, TCC = International Goth Couae%
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