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CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, <br />NA = Not applicable, UDC = Under-dispenser containment <br />UNDERGROUND STORAGE TANK <br />SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br />Type of Action Installation Test Repair Test Six Month Test 36 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10182103 <br />Date of Secondary Containment Test <br />10/17/19 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />United Pacific #5446 <br />Business Site Address <br />1430 Country Club Blvd. <br />City <br />Stockton, Ca. <br />ZIP Code <br />95204 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Richard Thomas <br />Phone # <br />(916) 991 - 1100 <br />Contractor/Tank Tester License # <br />CSLB#803616 SWRB#06-1672 <br />ICC Certification # <br />5254736 <br />ICC Certification Expiration Date <br />11/03/2020 <br />III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br />Tank ID: (By tank number, stored product, etc.) T-1 87 T-2 91 T-3 Diesel T-4 Waste Oil <br />Tank Containment <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Product Piping Containment <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Remote Fill Piping Containment <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Vent Piping Containment <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Vapor Recovery Piping Containment <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Communication Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Turbine / Product Piping Sump <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Fill Riser Sump <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />Vent / Transition Sump ID: <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />UDC ID: #1-2 #3-4 #5-6 #7-8 <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />UDC ID: <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />UDC ID: <br />Tightness Test Result Pass Fail NA Pass Fail NA Pass Fail NA Pass Fail NA <br />All items marked “Fail” or “N/A” 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 3, <br />chapter 16, section 2637 and all the information contained herein is accurate. <br />UST Service Technician Signature <br /> <br />