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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 10156819 9/ 15/2020 Business Name (Same as Facility Name or DBA-Doing Business As) Safeway #2600 Business Site Address City ZIP Code 1987 W. 11 th St. Tracy 95376 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Michael McCarter (707 ) 545-5522 Contractor / Tank Tester License ; ICC Certification # ICC Certification Expiration Date Able Maintenance , Inc. - 312844 8819839 10/15/2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) A 87 B 91 C Diesel D Tank Containment Tightness Test Result ® Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑ Pass m Fail ❑ NA ❑ Pass ® Fail ❑ NA ® Pass ❑ Fail ❑ NA ❑ Pass ® Fail ❑ NA Communication Test Result ❑ Pass 0 Fail ❑ NA ❑ Pass 21 Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 21 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail VI 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 0 Pass ❑ Fail ❑ NA ❑ Pass 0 Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA PW VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA UDC ID : 11 /2 23/4 35/6 47/8 Tightness Test Result ❑ Pass m Fail ❑ NA ❑ Pass ® Fail ❑ NA ❑ Pass m Fail ❑ NA ❑ Pass ® Fail ❑ NA UDC ID : 59/10 611 /12 713/ 14 815/ 16 Tightness Test Result ❑ Pass 0 Fail ❑ NA ❑ Pass ® Fail ❑ NA ❑ Pass 0 Fail ❑ NA ❑ Pass 0 Fail ❑ NA UDC ID : 917/18 jal019/20 11 12 Tightness Test Result ❑ Pass m Fail ❑ NA ❑ Pass ® Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA All items marked "Fail' or "NA " must be explained in their respective "COMMENTS " section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CON D4Crt11 G7,THI&PI ESTING, I 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. (� ( . i UST Service Technician Signature � : CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council NA -Not Appljcpble, UDC = Under- Dispenser Containment j