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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 ®36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10184805 18/16/2019 Business Name(Same as Facility Name or DBA-Doing Business As) Food 4 Less Business Site Address City ZIP Code 610 Cherokee Ln. I Lodi 95240 II. 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 III. 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 m Pass ❑Fail ❑NA m Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Product Piping Containment Tightness Test Result ❑Pass 0 Fail ❑NA ❑Pass m Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail 0 NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail 0 NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Vent Piping Containment Tightness Test Result ®Pass ❑Fail ❑NA m Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass m Fail ❑NA ❑Pass ®Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Turbine/Product Piping Sump Tightness Test Result m Pass ❑Fail ❑NA m Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Fill Riser Sump Tightness Test Result m Pass ❑Fail ❑NA 0 Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA VENT/TRANSITION SUMP ID: a b C d Tightness Test Result ❑Pass ❑Fail m NA ❑Pass ❑Fail m NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA UDC ID: 11/2 23/4 35/6 4 Tightness Test Result ❑Pass m Fail ❑NA ❑Pass m Fail Cl NA ❑Pass m Fail ❑NA ❑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 ❑Pass ❑Fail ❑NA ❑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 CONDUC I hereby certify that the secondary containment was tested in accordance with California Codi 6L-Regulations,Title 23,Div_ i.F 3,Chapter 16,Section 2637 and all the information contained herein is accurate. UST Service Technician Signature -t— 5 E P 2 2019 CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=Intematior�F ��apl�,UpG Dispenser Containment DEPARTMENT