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�- RECEIVED <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use ig B 8 2015 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures an <br /> printouts from tests(if applicable),should be provided to thefacility owner/operatorfor submittal to the local ENT/A 1. <br /> 1. FACILITY INFORMATION HFAIT►t nFnem2APW <br /> Facility Name: COSTCO#658 Date of Testing: 2/04/2015 <br /> Facility Address: 3250 WEST GRANT LINE,TRACY,CA 95304 <br /> Facility Contact: I Phone: <br /> Date Local Agency Was Notified of Testing: 1/27/2015 <br /> Name of Local Agency Inspector(i(present 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 License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date TrainingEx ices <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 ❑ ❑ UDC 9/10 ® ❑ ❑ ❑ <br /> 87-A Sec Line ❑ UDC 11/12 ® ❑ ❑ ❑ <br /> 87-B Sec Line 87-1 Fill Sump ❑ ❑ <br /> 91-A Sec Line ® ❑ ❑ ❑ 87-2 Fill Sump ❑ ❑ ❑ <br /> 91-B Sec Line ® ❑ 91 Fill Sump ❑ ❑ ® ❑ <br /> V/R 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 ® ❑ 11 0 Additive Fill Bucket ❑ El ❑ <br /> 91 STP Sump ® ❑ ❑ 87-1 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 1/2 ❑ ® ❑ ❑ 87-2 Vapor Bucket ® ❑ ❑ ❑ <br /> UDC 3/4 ® ❑ ❑ ❑ 91 Vapor Bucket ® ❑ ❑ ❑ <br /> JW 5/6 ❑ ❑ Additive Vapor Bucket ❑ El 1 ❑ <br /> UDC 7/8 -9-7 Ll I Ll I ❑ IT <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,t1&e cls toted in this document are/accurate and in full compliance with legal requirements <br /> Technician's Signature: � j/ Date:_2/04/2015 <br />