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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 9 36 Month Test CERS = California Environmental Reporting System, ID =Identification, UST =Underground Storage Tank, ICC = International Code Council, NA= NotApplicable, UDC = Under - Dispenser Containment 1. FACILITY INFORMATION CERS ID 10182251 Date of Secondary Containment Test 6/10/2020 Business Name (Same as Facility Name or DBA -Doing Arch Arco AmPm Business As) Business Site Address 4855 South Hwy 99 East Frontage Road City Stockton ZIP Code 95215 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Benjamin Duncan Test (Print as shown on the ICC Certification) Phone # (707) 621-0378 Contractor / Tank Tester License # Tank Tester License #90-1120 ICC Certification # 5246802 -UT ICC Certification Expiration Date 3/21/2021 111. SUMMARY OF SECONDARY CONTAINMENT TESTING HP wqpw RESULTS TANK ID: (By tank number, stored product, etc) A T -1 -Regular 87 B T -2 -Plus 89 C T -3 -Super 91 D Tank Containment Tightness Test Result O Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result E Pass ❑ Fail ❑ NA O Pass ❑ Fail ❑ NA Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result E Pass ❑ Fail ❑ NA R Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill Piping Containment Tightness Test Result ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail O NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail ❑ NA Vent Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Vapor Recovery Piping Containment Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Turbine / Product Piping Sump Tightness Test Result E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Fill Riser Sump Tightness Test Result ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail ❑ NA b C d VENT / TRANSITION SUMP ID: a Tightness Test Result ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail R NA ❑ Pass ❑ Fail ❑ NA 1 1&2 2 3&4 3 5&6 4 7&8 UDC ID: Tightness Test Result R Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA R Pass ❑ Fail ❑ NA UDC ID: 5 9&10 6 11&12 7 13&14 8 15&16 Tightness Test Result R Pass ❑ Fail ❑ NA R Pass ❑ Fail ❑ NA R Pass ❑ Fail ❑ NA R Pass ❑ Fail ❑ NA UDC ID: 9 17&18 10 11 12 Tightness Test Result R 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 CONDUCTING THIS TESTING I hereby certify that the secondary containment was tested in accordance with California Code of Regulations, Title 3, Chapter 16, Section 2637 and all the information contained herein is accurate. UST Service Technician Signature 23, Division