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Page 1 of 3 <br /> Secondafy Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriatepages ofthis form to report results for all components tested. The completedform, written test procedures, and <br /> printouts from tests (fapplicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO#658 1 Date of Testing: 3/20/2012 <br /> Facility Address: 3250 WEST GRANTLINE RD,TRACY,CA 95304 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 3/13/2012 <br /> Name of Local Agency Inspector(fpresent 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 License Number 300345 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Traming Expires <br /> Fumished 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 /> 87 Sec Line ® ❑ ❑ M 11 11 11 ❑ <br /> UDC 5/6 ® ❑ ❑ E ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ I Ell ElJE01 <br /> ❑ ❑ ❑ ❑ ❑ <br /> Ll El L1 <br /> ❑ ❑ ❑ ❑ ❑ <br /> 0 L Ll Ll Ell D1 El D <br /> ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ ❑❑ ❑ ❑ ❑ Ell I ❑ I I ❑ ❑ Ll ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> One(1), 55-gallon drums was 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: J'—yCWDate: 3/20/2102 <br />