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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 ❑x 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10184349 1 11 /25/2019 Business Name (Same as Facility Name or DBA-Doing Business As) Pilot Flying J #617 Lodi Business Site Address City ZIP Code 15100 N . Thornton Rd . Lodi 95242 II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification) Phone # Jacob Weaver (209) 3394067 Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date 804431 A , B HAZ 8338858 - UC 2/ 14/2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number, stored product, etc.) A T- 1 B T-2 C T-3 D T4 Tank Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA Product Piping Containment Tightness Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA Communication Test Result O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA Communication Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail [] NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA Turbine / Product Piping Sump Tightness Test Result E Pass ❑ Fail ❑ NA ❑ Pass E Fail ❑ NA ❑ Pass E Fail ❑ NA ❑ Pass E Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass E Fail ❑ NA ❑ Pass E Fail ❑ NA ❑ Pass E Fail ❑ NA ❑ Pass E Fail ❑ NA VENT / TRANSITION SUMP ID : a b C d Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA UDC ID : 1 1 -2 2 3-4 3 5-6 4 7-8 Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass E Fail ❑ NA UDC ID : 5 9- 10 6 11 -12 7 13 8 14/15 Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass E Fail ❑ NA E Pass ❑ Fail ❑ NA UDC ID : 9 16/17 10 18 11 12 Tightness Test Result ❑ Pass E Fail ❑ NA E 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 CONDUCTING THIS TESTING I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, Title 23, Division , 3 , Chapter 16, Section 2637 and all the information contained herein is accurate . UST Service Technician Signature CERS = Califomia Environmental Reporting System, ID = Identification, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- Dispenser Containment