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Oct, 29. 2018 1 : 15PM Donlee Pump Co No. 0917_P. 2 UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of s) Type of Action I]Installation Test ❑Repair Test ❑Six Month Test 6 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment-rest 10399867 10/25/2018 21 Business Name(Same a$Facility Name or DBA-Doing Business As) ER Vine Stockton I i` Business Site Address city H F40 T {g1/I_N� 4733 S. Hw 99 Frontage Road Stockton 9521 II. UNDERGROUND STORAGE.TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certl(leatlon.) Phone# Mario Romero (209)537 -9396 Ext. ContractorlTank Tester License# ICC Certification# ICC Cenlfication Expira on Date 8034353 20�'� � kIlk ill. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID:(By tank number,stored product,etc.) A '�- B 0t65(? I D Tank Containment Tightness Test Result —Pass ❑Fail ❑NA z Pass ❑Fall ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fall ❑NA Product Piping Containment 1=r_ _ _ - _ - _ - = 'rr Tightness Test Result Pass ❑Fail ❑^NA Pass []Fall ❑NA ffjass ❑Fall [j NA ❑Pass 0 Fail ❑NA Communication Test Result ❑Pass ❑Fall ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Remote Fill Piping Containment— WERM-11 31' Tightness Test Result ❑Wass ❑Fail NA Pass ❑Fall CaU ❑Pass ❑Fall M14A ❑Pass ❑Fall ❑NA Communication Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fall C]NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fall ❑NA Vent Piping containment Tightness Test Result ❑Pass ❑Fall a A D4pass ❑Fail RMA ❑Pass ❑Fail 011A ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fall ❑NA ❑Pass ❑Fail ❑NA ❑Pass Cl Fail ❑ NA ❑Pass ❑Fall [❑NA Vapor Recovery Piping Containment Tightness Test Result [�Pass ❑Fail NA ❑Pass ❑Fail @SIA ❑Pass ❑Fail NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA C]Pass ❑Fall [I NA ❑Pass ❑Fail ❑NA Turbine I Product Piping Sump - - WE - - Tightness Test Result Pass [3Fail [INA Kpa,ss ❑Fall [I NA ❑Pass Fail ❑NA -❑Pass ❑Fail ❑NA Fill Riser Sump - Tightness Test Result ❑Pass ❑Fall eNA ❑Pass [a Fail ENA ❑Pass ❑fail ❑Pass ❑Fail ❑NA Vent I Transition Sump ID. a b C d Tightness Test Result ❑Pass ❑Fall NA ❑Pass L]Fall NA Pass ❑Fail NA [I Pass El Fall []NA UDC ID: 2 79 4 Tightness Test Result Pass ❑Fall CI NA 1J�,n Pass 13 Fait ❑NA ass [I Fail ❑NA Dass [I Fail ❑NA UDc 10: 5 a 6 E36 7 9 8 Tightness-rest Result Pass ❑Fall ❑NA Rr Pass ❑Fail [INA Pass ❑Fail ❑NA ePass ❑Fall J3 NA UDC ID: 9 10 �( �NA 12 Tightness Test Result Pass [I Fail ❑NA Pass ❑Fall ❑ Pass ❑Fail ❑NA ❑Pass ❑Fall ❑NA All items marked"Fall'or"N/A"must be&planed In their respeollve"CorAMENTS"vection: — -- -- - — — IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING 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. UST So Ice Technic' Ignature CERS=California Environmental Reporting System,ID=ldcntifieation,UST=Underground storage tank,TCC Tnternationel Code Council,