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3WRCB,January 2002 • • <br /> Page of <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contradorsperf <br /> appropriate pages ofthormingperiodic testing of USTsecondary containment systems. Use the <br /> printouts from tes isform to report� results for.al_.l.components tested. The completedform,written test procedures, and <br /> --- , <br /> Costco#038 •tltty owner/operator for submittal to the local regulatory agency. <br /> Facility Name: 1616 East Hammer Lane RMATION <br /> Facility Address Stockton, Ca 95210 Date of Testing: 7-2 �_ <br /> Facility Contact Nick Harvey <br /> #11590 SB 989 Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector tifpresem during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Inc <br /> Technician Conducting Test <br /> Credentials: ❑CSLB Licensed Contractor 'mac ICC# %/ 7.P <br /> ❑SWRCB Licensed Tank Tester <br /> License Type: A,B,c10,C21/D40 Haz License Number: 300345 <br /> Manufacturer Alanufaetur_ erTrainin <br /> Com onent(s Date Tr ' <br /> am <br /> Furnished U on Re uest mg E ues <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs <br /> Tested Made Component Pass Fall Not Repairs <br /> ❑ ❑ ❑ Tested Made <br /> ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ L] ❑ ❑ <br /> ❑ ❑ LI ❑ ❑ ❑ ❑ ❑ <br /> ❑ 11 11 ❑ ❑ ❑ ❑ <br /> El ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> D EI <br /> 11 ❑ ❑ ❑ ❑ El ❑ ❑ <br /> ❑ <br /> ❑ ❑ ❑ ❑ 11 ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best ofrny knowledge,the facts stated ht tills document are accurate and ht full compliance with legal requirements <br /> Technician's Signature: <br /> Date: 7- 2 S-// <br />