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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 10181313 2/26/2020 Business Name(Same as Facility Name or DBA-Doing Business As) Lodi Food & Liquor Business Site Address City ZIP Code 1225 West Lockeford Street Lodi 95240 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification) Phone# Benjamin Duncan (707) 621-0378 Contractor/Tank Tester License# ICC Certification# ICC Certification Expiration Date Tank Tester License #90-1120 5246802-UT 3/21/2021 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS TANK ID: (By tank number,stored product, etc.) A T-1-87 B T-2-91 C T-3-Diesel D Tank Containment Tightness Test Result Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA Z Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Product Piping Containment Tightness Test Result Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Communication Test Result Z Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA E Pass ❑ Fail ❑ NA ❑ Pass ❑ Fail ❑ NA Remote Fill 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 Z NA ❑ Pass ❑ Fail E 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 [IFail E NA ❑ Pass El Fail ENA ❑ Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA Communication Test Result ❑ Pass ❑ Fail Z 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 E NA ❑ Pass ❑ Fail E NA ❑Pass ❑ Fail E NA ❑ Pass ❑ Fail ❑ NA VENT/TRANSITION SUMP ID: a b 11 C d Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail E NA 11 ❑ Pass ❑ Fail E NA ❑Pass ❑Fail ❑ 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 E Pass ❑ Fail ❑NA UDC ID: 5 6 7 8 Tightness Test Result ❑ Pass ❑Fail ❑ NA ❑ Pass ❑ Fail ❑ NA ❑ Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑ NA UDC ID: 9 10 11 11 12 Tightness Test Result ❑ Pass ❑ Fail ❑ NA 11 ❑ Pass ❑Fail ❑NA 11 ❑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 nnnccoonnftained herein is accurate. UST Service Technician Signature `i�lt� .J"_lJl�f7Arlft'� CERS=California Environmental Reporting System,ID=Identification,UST=Underground Storage Tank,ICC=International Code Council,NA=Not Applicable,UDC=Under- Dispenser Containment