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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. 11th 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 111 . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) E 87 South F 91 South G Diesel South H Tank Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result ❑ Pass m Fail ❑ NA ❑ Pass ® Fail ❑ NA ❑ Pass m Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass 21 Fail ❑ NA ❑ Pass ® Fail ❑ NA ❑ Pass 21 Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 91 NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail V] NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ® NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail m NA ❑ Pass ❑ Fail m 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 ❑ Pass ❑ Fail p NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail VI NA ❑ Pass ❑ Fail ❑ NA VENT / TRANSITION SUMP ID : e f 5 h Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 13 14 15 16 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 17 18 19 20 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 21 22 23 24 Tightness Test Result ❑ Pass ❑ 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 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 CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = Intemational Code Council, NA = Not Applicable, UDC = Under- Dispenser Containment i