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1 <br /> UNDERGROUNDSTORAGETANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page1 of6) <br /> Type of Action ❑Installation Test ❑Repair Test ❑Six Month Test 0 36 Month Test <br /> I. FACILITY INFORMATION fi <br /> CERS ID Date of Secondary Containment Test <br /> 10182251 6/10/2020 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> Arch Arco AmPm <br /> Business Site Address City ZIP Code <br /> 4855 South Hwy 99 East Frontage Road Stockton 95215 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the/CC Certification) Phone# <br /> Benjamin Duncan (707) 621-0378 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Tank Tester License #90-1120 5246802-UT 3/21/2021 <br /> Ill. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID: (By tank number,stored product, etc.) A T-1-Regular 87 B T-2-Plus 89 C T-3-Super 91 D <br /> Tank Containment <br /> Tightness Test Result O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA Z Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result E Pass ❑Fail ❑NA O Pass ❑ Fail ❑ NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result E Pass ❑Fail ❑NA E Pass ❑ Fail ❑ NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail O NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail O NA ❑Pass ❑ Fail O NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail O NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Communication Test Result ❑ Pass ❑Fail Z NA ❑ Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> Turbine/Product Piping Sump <br /> Tightness Test Result E Pass ❑Fail ❑NA E Pass ❑ Fail ❑ NA E Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑Fail E NA ❑Pass ❑Fail ❑NA <br /> VENT/TRANSITION SUMP ID: a b C d <br /> Tightness Test Result ❑Pass ❑Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail O NA ❑Pass ❑ Fail ❑ NA <br /> UDC ID: 1 1&2 2 3&4 3 5&6 4 7&8 <br /> Tightness Test Result E Pass ❑Fail ❑ NA E Pass ❑ Fail ❑NA Z Pass ❑ Fail ❑NA E Pass ❑Fail ❑NA <br /> UDC ID: 5 9&10 6 11&12 7 13&14 8 15&16 <br /> Tightness Test Result Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑NA E Pass ❑Fail ❑ NA E Pass ❑Fail ❑ NA <br /> UDC ID: 9 17&18 10 11 12 <br /> Tightness Test Result E Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA E]Pass E] 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 />