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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action ❑ Installation Test ❑ Repair Test ❑ Six Month Test ❑x 36 Month Test <br /> I. FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10181391 10/14/2019 <br /> Business Name(Same as Facility Name or DBA-Doing Business As) <br /> St. Joseph's Medical Center <br /> Business Site Address City ZIP Code <br /> 1800 North California Street Stockton 95204 <br /> II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# <br /> Benjamin Duncan (707) 621-0378 <br /> Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date <br /> Afford-a-test/90-1120 5246802-UT 3/23/2021 <br /> III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID: (By tank number,stored product,etc.) A T-1-Fuel Oil B C D <br /> Tank Containment <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Product Piping Containment <br /> Tightness Test Result E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA <br /> Remote Fill Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail M NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Vent Piping Containment <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑NA ❑Pass ❑ Fail ❑NA <br /> Communication Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA ❑Pass ❑ Fail ❑NA <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> Communication Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> Turbine/Product Piping Sump <br /> Tightness Test Result E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA <br /> Fill Riser Sump <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑NA ❑ Pass ❑ Fail ❑NA <br /> VENT/TRANSITION SUMP ID: a b C d <br /> Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑Fail <br /> El <br /> ❑Pass ❑ Fail ❑NA ❑Pass ❑ Fail ❑NA <br /> UDC ID: 1 2 3 4 <br /> Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> UDC ID: 5 6 7 8 <br /> Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA <br /> UDC ID: 9 10 11 12 <br /> Tightness Test Result ❑ Pass ❑Fail E NA ❑ Pass ❑Fail E NA ❑Pass ❑ Fail E NA ❑Pass ❑ Fail E NA <br /> All items marked"Fail"or"NA"must be explained in their respective"COMMENTS"section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations,Title 23, Division <br /> 3, Chapter 16, Section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- <br /> Dispenser Containment <br />