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UNDERGROUND STORAGE TANK <br />SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br />Type of Action El Installation Test 0 Repair Test 0 Six Month Test El 36 Month Test <br />I. FACILITY INFORMATION <br />CERS ID <br />10181341 <br />Date of Secondary Containment Test <br />11/20/2018 <br />Business Name (Same as Facility Name or DBA-Doing Business As) <br />Chevron 99840 <br />Business Site Address <br />4344 E Waterloo Rd <br />City <br />Stockton <br />ZIP Code <br />95215 <br />II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br />Name of UST Service Technician Performing the Test (Print as shown on the ICC Certification.) <br />Nick Harvey <br />Phone # <br />(916)834 - 5099 Ext. <br />Contractor/Tank Tester License # <br />300345 A B C61/D40 HAZ <br />ICC Certification # <br />5115738 <br />ICC Certification Expiration Date <br />02/13/2019 <br />III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br />Tank ID: (By tank number, stored product, etc.) A 87 B 91 C D <br />Tank Containment <br />Tightness Test Result Eg Pass EI Fail 0 NA Z Pass D Fail 0 NA CI Pass 0 Fail 12 NA 0 Pass 0 Fail 0 NA <br />Product Piping Containment <br />Tightness Test Result Z Pass 0 Fail 0 NA E1 Pass D Fail 0 NA 0 Pass 0 Fail D NA 12 Pass 0 Fail 0 NA <br />Communication Test Result Z Pass 0 Fail 0 NA Z Pass C1 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Remote Fill Piping Containment <br />Tightness Test Result 0 Pass 0 Fail Z NA 0 Pass 0 Fail Z NA 0 Pass 0 Fail 0 NA 0 Pass CI Fail D NA <br />Communication Test Result 0 Pass 0 Fail Z NA 0 Pass 0 Fail Z NA 12 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA <br />Vent Piping Containment <br />Tightness Test Result 0 Pass 0 Fail Z NA 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 12 NA <br />Communication Test Result 0 Pass 12 Fail Z NA 0 Pass 0 Fail Z NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Vapor Recovery Piping Containment <br />Tightness Test Result 0 Pass 0 Fail [E] NA 0 Pass 0 Fail Z NA 0 Pass 0 Fail 0 NA El Pass 0 Fail 0 NA <br />Communication Test Result 0 Pass 0 Fail Z NA 0 Pass 0 Fail El NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Turbine / Product Piping Sump <br />Tightness Test Result Z Pass 0 Fail 0 NA Z Pass 0 Fail 0 NA 0 Pass E) Fail 0 NA 0 Pass 0 Fail 0 NA <br />Fill Riser Sump <br />Tightness Test Result Z Pass 0 Fail 0 NA Z Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />Vent / Transition Sump ID: a b c d <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 12 NA <br />UDC ID: 1 1/2 2 3/4 35/6 4 7/8 <br />Tightness Test Result Z Pass CI Fail CI NA El Pass 0 Fail 0 NA El Pass 0 Fail 0 NA Z Pass 0 Fail 0 NA <br />UDC ID: 5 6 7 8 <br />Tightness Test Result 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail CI NA <br />UDC ID: 9 10 11 12 <br />Tightness Test Result 0 Pass El Fail D NA 0 Pass 12 Fail 0 NA 0 Pass 0 Fail 0 NA 0 Pass 0 Fail 0 NA <br />All items marked "Fail" or "N/A" 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, <br />division 3, chapter 16, section 2637 and all the information contained herein is accurate. <br />UST Service Technician Signature <br />LiIt-z <br />CERS = California Environmental Reporting System, ID = Identification, UST = Underground storage tank, ICC = International Code Council, <br />NA = Not applicable, UDC = Under-dispenser containment