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• 0 Page 1 of 11 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(ifapplicable), should be provided to thefacility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO#038 1 Date of Testing: 9/04/2013 <br /> Facility Address: 1616 E.HAMMER LANE,STOCKTON,CA 95210 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 8/26/2013 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Incorporated <br /> Technician Conducting Test: NICK HARVEY ICC#5115738 <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,HAZ,C21,C10,B,C61,D40 I License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Furnished on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Annulars(Wet) ❑ ® ❑ UDC 7/8 ❑ ® ❑ <br /> 87 Sec Line ❑ ® ❑ UDC 9/10 ❑ ® ❑ <br /> 91 Sec Line ® ❑ ❑ ❑ UDC 11/12 ❑ ® ❑ <br /> V/R Sec Line ® ❑ ❑ ❑ 87-1 Fill Sump ❑ ❑ ® ❑ <br /> 87 Syphon Sec Line ❑ ❑ ❑ 87-2 Fill Sump ❑ ® ❑ <br /> Additive Sec Line ❑ ❑ ® ❑ 91 Fill Sump ❑ z ❑ <br /> 87-1 STP Sump ® ❑ ❑ I ❑ Additive Sump ❑ I El Z I ❑ <br /> 87-2 STP Sump ® ❑ ❑ ❑ 87-1 Fill Bucket ❑ ❑ <br /> 91 STP Sump ® ❑ ❑ ❑ 87-2 Fill Bucket ❑ <br /> Vent Stack Fuel ® ❑ ❑ ❑ 91 Fill Bucket ® ❑ ❑ ❑ <br /> Vent Stack Additive ❑ ❑ ® ❑ 87-1 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 1/2 ® ❑ ❑ ❑ 87-2 Vapor Bucket ® ❑ ❑ <br /> UDC 3/4 ❑ ❑ ❑ 91 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 5/6 ® ❑ ❑ Additive Fill Bucket ® ❑ ❑ ❑ <br /> Additive Vapor Bucket ® ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Five(5) 55-gallon drums were left on site <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: � C�, �' Date:_9/04/2013 <br />