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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) Type of Action ❑ Installation Test ❑ Repair Test N Six Month Test N 36 Month Test I . FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10182313 02/ 13/ 19 Business Name (Same as Facility Name or DBA-Doing Business As) Chevron 208117 Business Site Address City ZIP Code 755 S . Trac Blvd TracT95376 II , UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) Phone # Nick Harvey (714) 826 - 0352 Ext. Contractor/Tank Tester License # ICC Certification # ICC Certification Expiration Date 300345 A B C61 /D40 c HAZ 5115738 01 / 11 /2021 III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID : (By tank number, stored product, etc.) A 87- 1 B 91 C D Tank Containment Tightness Test Result ® Pass ❑ Fail ❑ NA ® Pass El Fail ❑ NA El ❑ Fail ❑ NA ❑ Pass 171 Fail ❑ NA Product Piping Containment I Tightness Test Result S Pass ❑ Fail ❑ NA S Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result N Pass E] Fail E] NA S Pass ❑ Fail F1 NA Pass ❑ Fail E] NA 171 Pass E] Fail E] NA Remote Fill Piping Containment Tightness Test Result ElPass ElFail S NA ElPass E] Fall N NA El Pass El Fail El NA El Pass El Fail ❑ NA Communication Test Result El Pass ElFail N NA ElPass ❑ Fail N NA ❑ Pass ElFail ElNA ❑ Pass ❑ Fail ❑ NA `r i Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail N NA ❑ Pass ElFail N NA ElPass ElFail ElNA ❑ Pass El Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail S NA ❑ Pass ❑ Fail S NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail S NA ❑ Pass ❑ Fail N NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result S Pass ❑ Fail ❑ NA S Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result N Pass ❑ Fail E] NA N Pass ElFail ❑ NA ElPass El Fall ElNA 171Pass 171Fail ❑ NA Vent / Transition Sump ID : a b C d Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 1 1 /2 23/4 35/6 4 7/8 Tightness Test Result N Pass ❑ Fail ❑ NA S Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA UDC ID : 59/ 10 611112 7 8 Tightness Test Result N Pass ❑ Fail ❑ NA N Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA UDC ID : 9 10 11 12 Tightness Test Result ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA I ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA All items marked "Fail" or "N/A " 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 , Q CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, NA = Not applicable, UDC = Under-dispenser containment