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�ia;EIVEI <br /> JUN 0 S 2015 <br /> Secondary Containment Testing Report Form FF�_� ``,,IIpp((�� <br /> This form is intendedfor use by contractors performing periodic testing of UST secondary containment systerns.NJq RONMENTAL <br /> IJ n 790ThAM17 <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procE�es', an; <br /> printouts from tests(j applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> I. FACILITY INFORMATION <br /> Facility Name: Costco#658 1 Date of Testing:2015-05-27 <br /> Facility Address: 3250 W. GRANT LINE,TRACY CA 95377 <br /> Facility Contact: Dennis Bock I Phone (425)427-7653 ❑Initial m Repair Test <br /> Date Local Agency Was Notified of Testing: 2015-04-30 ❑6 Month ❑Other <br /> Name of Local Agency Inspector(ifpresent during testing): Michelle Henry ❑Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nicholas Harvey ICC#5115738 <br /> Credentials: m CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester m ICC UST Service Technician <br /> License Type: AC21C10BC61D40HAZC34C57 License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Furnished upon request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Sec line 87A m ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 1/2 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> UDC 5/6 ❑ ® ❑ 717T— ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> El El ❑ ❑ <br /> ❑ ❑ ❑ ❑ <br /> ❑ ❑ <br /> ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> No drums were left on site <br /> For any equipment capable of generating a print out of test results,you must attach a copy <br /> of the test report to this certification ❑ System printout attached. <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 Si �tpre V Date: 2015-05-27 <br />