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Page_of <br /> SWRCB,January 2002 <br /> Secondary Containment Testing Report Form <br /> This farm is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate <br /> pages of this form to report results for all components tested The completed form, written test procedures, and printouts from tests <br /> (if applicable), <br /> should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: Costco Wholesale-TRACY-0658 Date of Testing: 11/ ID <br /> Facility Address: 3250 W.GRANTLINE RD,TRACY,CA 95377 �f <br /> Facility Contact: Corbin,Chris Phone:(209)834-1247 <br /> Date Local Agency Was Notified of Testing: 10/29/2015 <br /> Name of Local Agency Inspector(fpresent during testing): L <br /> 2. TESTING CONTRACTOR INFORMATION HFAITH nP0110TAAFRIT <br /> Company Name:Belshire Environmental Services,Inc. <br /> Technician Conducting Test: Mauricio Dominguez <br /> Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A-General Engineering ContractorLicense Number:808313 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Exp'res <br /> See Attached <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pus Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Tank Annulars ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Secondary Pie 1 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Piping Sump ❑ ❑ ❑ I ❑ ❑ ❑ ❑ ❑ <br /> UDC 2 ❑ © ❑ ❑ I t2 ❑ ❑ ❑ 1 ❑ <br /> Fill Sump ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Bucket ❑ ❑ ❑ Ll ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 171 Placed in drums left on site for proper disposition. <br /> �]Transported to next site for use in additional testing. <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the beat ofmy knowledge,the fads.stated in this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: Date: 11/16/2015 <br />