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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 9136 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10184829 8/13/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Food 4 Less Business Site Address City ZIP Code 1427 S . Airport Way Stockton 95206 IL 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 10/25/2019 111 . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID : (By tank number, stored product, etc.) A 87 B 91 C D Tank Containment Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fall ❑ 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 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result 0 Pass ❑ Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail p NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail 0 NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 11 /2 23/4 35/6 4 Tightness Test Result ❑ Pass 0 Fail ❑ NA ❑ Pass 0 Fail ❑ NA 0 Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 5 6 7 8 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fall ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 9 10 11 12 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ ' s CF All items marked "Fag" or "NA " must be explained in their respective "COMMENTS " section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTI G 1 hereby certify that the secondary containment was tested in accordance with California Code of Regu a i , TJtl Division 3, Chapter 16, Section 2637 and all the information contained herein is accurate. r �� ' ' UST Service Technician Signature j g .vACr $..I CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Count y+di 5 (i1 ,1j00C = Under- Dispenser Containment