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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page -I of 6) Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test ❑x 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10182307 10/ 16/2018 Business Name (Same as Facility Name or DBA-Doing Business As) Quicki Kleen Car Wash Business Site Address City ZIP Code 707 East Yosemite Ave . Manteca 195336 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Benjamin Duncan ( 707 ) 621 - 0378 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date Afford -a-test/90- 1120 524680MT 4/3/2019 Ill . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) A T- 1 -87-87-Diesel B C D Tank Containment Tightness Test Result E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result p Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ElFail E NA ❑ Pass ❑ Fail O NA 171Pass ElFail E NA ❑ Pass ❑ Fail E NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA i Turbine / Product Piping Sump Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump I E Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA VENT I TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA UDC ID : 1 1 &2 2 3&4 3 5&6 4 7&8 Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA UDC ID : 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 9 10 11 12 Tightness Test Result El Pass El Fail El NA El 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 hereby certify that the secondary containment was tested in accordance with California , 9f Ile ulalioki Trtle 23, Divr ion 3 , Chapter 16, Section 2637 and all the information contained herein is accurate. _ UST Service Technician Signature ,A P !� 0 �� l it G ' CERS = California Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Coundl, NA = Not Applicable, UDC = Under- Dispenser Containment aNk i z6 it�l ' € I 14t l pl l" 3