Testing and Inspection CertificateTanknology Inc.

11000 North MoPac Expressway, Suite 500, Austin, TX 78759800-800-4633 www.tanknology.com Page 1 of 1

Test Date 5/30/2017 Tanknology WO# MW1-6173728

Test Purpose COMPLIANCE Customer PO#

Customer Location

ANTHONY BLVD GAS STATION 7230 S. ANTHONY BLVD FORT WAYNE, IN 46816

ANTHONY BLVD GAS STATION (7230 S ANTHONY) 7230 S. ANTHONY BLVD FORT WAYNE, IN 46816

Attn: Chetty Sevugan Attn: Chetty Sevugan

(630) 257-6500

(630) 257-6500

Test / Inspection Description Item TestedDate

TestedResult

Precision Tank Tightness Tank 1 PREMIUM 5/30/2017 Pass Precision Tank Tightness Tank 2 REGULAR 5/30/2017 Pass Precision Tank Tightness Tank 3 PLUS 5/30/2017 Pass

Tanknology Representative: DanBatten Technician: Shawn Williams

Telephone: (614) 436-7600 Technician Certification: (See forms)

VacuTectTank Tightness Test

page 1 of 1

Work Order: 6173728 Date: 5/30/2017

Site Name/ID: ANTHONY BLVD GAS STATION

Address: 7230 S. ANTHONY BLVD

City: FORT WAYNE State: IN Zip: 46816

Tank Information

Customer Tank ID

Regulatory Tank ID

Product Category

Product Name

Gallons Capacity

Tank Type

Tank Walls

Compartmentalized

Siphon Tank

Vents included with test

Test Start Time

Test End Time

Water ingress (Y/N)

Bubble ingress (Y/N)

Ullage ingress (Y/N)

Test Result (P/F/I)

1 PREMIUM

1

Gasoline - Premium

PREMIUM

10000

Steel

Singlewall

No

No

with this tank

13:50:00

15:03:00

No

No

No

Pass

2 REGULAR

2

Gasoline - Regular

REGULAR

10000

Steel

Singlewall

No

No

with this tank

13:50:00

15:03:00

No

No

No

Pass

3 PLUS

3

Gasoline - Midgrade

PLUS

10000

Steel

Singlewall

No

No

with this tank

15:30:00

16:54:00

No

No

No

Pass

Yes No diagnostic only - Test was performed per 3rd party certifications as specified in 40 CFR parts 280 and 281.

Technician Comments :

Technician Name Shawn Williams Certification # UC2016IN11582

Technician Signature

Environmental Compliance for Petroleum Systems©2017 Tanknology Inc., Austin,TX. All rights reserved. tanknology.com

Site Diagram(This site diagram is for reference only and is not drawn to scale)

Work Order: 6173728

Site ID / Name: 7230 S ANTHONY / ANTHONY BLVD GAS STATION

Address: 7230 S. ANTHONY BLVD

City: FORT WAYNE State: IN Zip: 46816

Tanknology Inc.1 1 000 N. MoPac Expressway, Suite 500 Austin, TX 78759 (800) 964-0010

JOB CLEARAI{CE FORM &SITE SAFBTY CHECKLIST _ OVF

Policy 100-29-ARev: DRevised: 112412014

iite Name/#:

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Street Address:

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Travel Time: othgrs on srte: Date

f'30- r>Scope of Work and Tasks Performed (JSA's must be available for all tasks):

{'-*ksRepairs io Equipment or Parts Provided:

Follow-up aciions required; equipmeni isolated; comments:

PPE - PERSONAL PROTECTIVE EQUIPMENT REQUIRED (Check items used or mark - if not apa!!9eb!9)

wd

Safety VestSteel Toe Boots

f,n

Safety Glasses

Splash Goggles

Z Gloves

E Hard Hat

E Hearing Protection

n other

1.

2.

3.

4.

5.

/ PRE-TEST PROCEDURES rcnecx eacn nem compteted or mark - if not appticabte)

Ei' Discuss safety procedures with site personnel. Nearest hospital:

V prior to fuel deliveries the UST system must be placed back into working order.

E/ Secrre entire work area with barricades (cones, flags, and caution tape, pennant flags, or other perimeter guard).

W,Place fire extinguishers and "No Smoking" signs in the work area./ lmplement LockouUTagout per API 1646 (when accessing2roduct piping during tasks)

E, All applicable equipment disabled during test(s). Zr,$ecure the circuit breaker(s) with lockout devices and tags.

dS."rrc nozzles with "Out of Service" bags and nylon ties. 4 Verify LOTO is complete by trying to operate pumps.

6 Close balt valves or check valves on product piping. ! Disconnect electrical "bayonet" connector from the STP(s).Leao lecnnrdan Name

,--1 ,

\\rt " ,,,rt/:ll/)-,* t {d":;:.ls a fuel delivery due today?

General Safety Checks:All site personnel have been informed.Fuel delivery has been informed.

LOTO procedures have been discussed and agreed.Work areas barricaded to protect workers, staff & public. Ded'J Lrsse

I have discussed iob clearance form with technician-

/ POST-TEST PROCEDURES rcnecx eacn item comptetea or marx - if notappticaotet

1. fuR.-ou. all "LockouVTagout" devices.2. ff prnall pumpsandverifytherearenoleaks: n lmpactValveTestPortsunderdispensers

E Leak Detector Threads on STP's E Functional Elements & Relief Screws

3. E lnstall lead wire seal on all test plugs & leak detectors that were serviced.Count LD threads: L1 L2 L3 L4 L5 L6

4. V CnecXfollowing compone-nts operatlonal: ffietCprO"r,."*, & caps

V eal floats, dry breaks & caps E Cathodic protection operationalE Containment sumps are dry n Dispensers & POS operationaln Dispenser panels are replaced "E- Drop tubes, fill adapters & capsn Leak detectors & vent tubes ^E/ Manhole covers and sump lids

E Monitoring system iS operational E Shear valves are openE Siphon lines and manifold valves E Siphon lines and manifold valvesn STP fittings and bayonet connectors E-Vents (not capped, plugged or isolated)

5. n Remove barricades.I I

(ih, ,^,,tt lnJ,'ilr** %r7Z'General Safety Checks:

Work area has been left tidy & safe.Sito otaff aro ayvare of work otatus including any remaining isolation

b,.ru.r,4.-r-E *E,juildilgE> tu equrPil tEilt dtY uuuuil lYI ttYu dilu uu[ lI tuilrudtvu

All incidents, near incidents, and unsafe siiuations repoded.

Site Representative Comments:

COMPANY CONFIDENTIAL O Tanknology Inc., 2011. All Rights Reserved.

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