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UNDERGROUND STORAGE TANK i <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action r Installation Test [' Repair Test r Six Month Test WF 36 Month Test <br /> 1. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test: <br /> 10166017 8/22/2019 <br /> Business Name ( Same as Facility Name or DBA-Doing Business As) <br /> 7- ELEVEN #32190 , MKT 2368 <br /> Business Site Address City: Zip : <br /> 4943 S . KINGSLEY (FRONTAGE RD) HWY 99 @ ARCH AIRPORT RD STOCKTON 95206 <br /> 11, UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test ( Print as shown on the ICC Certification . ) Phone # <br /> Jarrod Cooke (800) 8004633 <br /> Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> Class A General Engineering 743160 5311523-UT 4/3/2021 <br /> III, SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> Tank ID: (By tank number, stored product, etc) T4 T5 T6 <br /> Tank Containment <br />' Tightness Test Result Passr Fair NA r Passr Fair NA r Passr Fair NA r Passr Fair NA <br /> Product Piping Containment <br /> Tightness Test Result r Passr Fair NA r Passr Fair NA r Passr Fair NA rPassr Fair NA <br /> Communication Test Result Passe Fair NA r Passr Fair NA r Passr Fair NA r Passr Fair NA <br /> RP <br /> Remote Fill Piping Containment <br /> I <br /> Tightness Test Result tF assr Failr NA r Passr Failr NA r Passr Failr NA r Passr Failr NA <br /> Communication Test Result Passr Failr NA r Passr Fair NA r Passr Failr NA r Passr Failr NA <br /> Vent Piping Containment <br /> Tightness Test Result Passr Failr NA r Passr Failr NA r Passr Fair NA r Passr Failr NA <br /> Communication Test Result [' PassF Failr NA r Passr Failr NA r PassF Failr NA r Passr Failr NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result [' PassF Fall [' NA r Passr Fair NA r Pass[' Failr NA r Passr Failr NA <br /> Communication Test Result r Passr Fail [' NA r Passr Failr NA r Pass[' Failr NA r Passr Fail[' NA <br /> Turbine / Product Piping Sump <br /> Tightness Test Result r Passr Failr NA r Passr Failr NA r Passr Failr NA r Passr Failr NA <br /> Fill Riser Sump <br /> Tightness Test Result Passr Fair NA W Passr Failr NA W Passr Failr NA r Passr Failr NA <br /> Vent / Transition Sump ID : a b c d <br /> Tightness Test Result r Passr Failr NA r Passr Fail [' NA r Passr Failr NA r Pass [' Failr NA <br /> UDC ID: 1 2 3 4 <br /> Tightness Test Result r Passr Failr NA r Passr Failr NA r Passr Failr NA r Passr Failr NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Result r PassrFailr NA r Passr Failr NA r Passr Failr NA r Passr Failr NA <br /> UDC ID: 9 10 11 12 <br /> Tightness Test Result r Passr Failr NA r Passr Failr NA r Passr Failr NA r Passr Failr NA <br /> All items marked "Fail' or "N/A " must be explained in their respective "COMMENTS " section. <br /> IVs CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS <br /> I hereby certify that the spill containers were tested in accordance with California Code of Regulations , title 23 , division 3 , chapter 16 , <br /> section 2637. 1 and all the information contained herein is accurate . <br /> UST Service Technician Signature <br /> CERS = California Environmental Reporting System , ] D = Identification , UST = Underground storage tank , ICC = International Code Council , <br /> NA = Not applicable , UDC = Under-dispenser containment <br />