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4 l UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM ( Page 1 of 6) <br /> VIrvf,yr ' 'Aetio I . Fy <br /> Installation Test El Repair Test E] Six Month Test 36 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10180881 11 /5/2018 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Tiger Express #2 Delta 88 Food & Gas <br /> Business Site Address City ZIP Code <br /> 5611 East Waterloo Road Stockton 195215 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # <br /> Benjamin Duncan ( 707 ) 621 -0378 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Afford - a -test/90 - 1120 5246802 - UT 4/3/2019 <br /> III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID : (By tank number, stored product, etc.) A T- 1 -87 B T-2-91 C T-3 - Diesel D <br /> Tank Containment <br /> Tightness Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result Z Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA <br /> Communication Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> Communication Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> TurbiEProduct Piping Sump <br /> TightnResult E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Fill RTightnResult ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail Z NA <br /> VENT / TRANSITION SUMP ID : a b C d <br /> Tightness Test Result ❑ Pass ❑ Fail Z NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E 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 6 7 8 <br /> Tightness Test Result E Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> UDC ID : 9 _ 10 11 12 <br /> Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ 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 /> t <br />