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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action ❑ Installation Test ® Repair Test ❑Six Month Test ❑36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10/31/2018 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Plaza Liquors & Gas <br /> Business Site Address City ZIP Code <br /> 2420 W Turner Rd Lodi 95242 <br /> 11. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# <br /> Joe Bartholdi (209) 461-6337 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Elite IV 1001331 A-HAZ 2851 11/8/2020 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID: (By tank number,stored product,etc.) A 87 B T-2 C T-3 D T-4 <br /> k t 7 � . <br /> Tank Containment <br /> ,u::, +�k_ .s,z <br /> Tightness Test Result E Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA <br /> �Product Piping Containment �.lf,l i* a ' <br /> t.. <br /> Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> 11 ffil` <br /> Remote Fill Piping Containment r �� � � . <br /> _. <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA <br /> Vent Piping Containment # ' <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA <br /> %g4 S`''c�'1g ;v^rr $r,e.: .5 *, e U <br /> e �`;a.'... til t {:vs�, '� @ <br /> Vapor Recovery Piping Containment ,< s yx � ,� <br /> Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Turbine/Product Piping Sump �, �, <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA <br /> FIII Riser Sump <br /> aa� xe� s, <br /> ,.�'* rte.. - .? <br /> Tightness Test Result ❑Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> VENT/TRANSITION SUMP ID: a b C d <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA <br /> UDC ID: 1 2 3 4 <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> UDC ID: 9 10 11 12 <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑Fail ❑NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑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 /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- <br /> Dispenser Containment <br />