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Page 1 of 9 <br /> Secondaty'Containment Testing Repot 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 completedform,written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO#658 1 Date of Testing: 2/07/2012 <br /> Facility Address: 3250 WEST GRANTLINE RD,TRACY, CA 95304 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: 1/26/2012 <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,CIO,B,C61,D40 I License Number: 300345 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Trammg Expi <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 ❑ ❑ ® 87-1 Fill Sump ® ❑ ❑ ❑ <br /> 87 Sec Line ❑ ® ❑ 87-2 Fill Sump ® ❑ ❑ ❑ <br /> 91 Sec Line ® ❑ ❑ 91 Fill Sump ® ❑ ❑ <br /> V/R&Vent Sec Line ® ❑ ❑ ❑ 87-1 Fill Bucket ® ❑ ❑ ❑ <br /> Syphon Sec Line ® ❑ ❑ ❑ 87-2 Fill Bucket ® ❑ ❑ <br /> 87-1 STP Sump ® ❑ ❑ ❑ 91 Fill Bucket ® ❑ ❑ ❑ <br /> 87-2 STP Sump ❑ ❑ ❑ 87-1 Vapor Bucket ® ❑ ❑ ❑ <br /> 91 STP Sump ❑ ❑ 87-2 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 1/2 ® ❑ ❑ ❑ 91 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 3/4 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ❑ ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 7/8 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 9/10 ® ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 11/12 ® ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was perforated,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 RESPONSHiLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,/theJfacts stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: , (/l � � Date:_2/07/2012 <br />