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SWRCB,January 2602 Page—of Secondary Containment Testing Report Form This form is intended for rise by contractors perforating periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed forth, switten test procedures, and printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1, FACILITY INFORMATION Facility Name: Costco Wholesale-TRACY-0658 1 Date of Testing:6/6/2016 Facility Address: 3250 W.GRANTLINE RD,TRACY,CA 95377 Facility Contact: Wierderholt,Michael Phone:(209)834-1247 Date Local Agency Was Notified of Testing; 5/20/2016 _ Name of Local Agency Inspector(ifpresent during testing); �... •.- 2. TESTING CONTRACTOR INFORMATION JUN 2 �. Company Name:Belshire Environmental Services,Inc. Technician Conducting Test:Saul Gonzalez , Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester .' - License Type: A-General Engineering Contractor License Number:808313 Manufacturer Tr:tirrin Manufacturer Component(s) Date Training Expires See Attached 3, SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs ComponentPass Pall Not Repairs Tested Made Tested Made Tank Annulars ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Secondary Pie ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ UDC 1 u ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Sum ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ Spill Bucket ❑ 1 ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests; 0 Placed in drums left on site for proper disposition. Transported to next site for use In additional testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of»ry knowledge, the facts stated in this document airy accurate and in full compliance with legal requirements r T � - Technician's Signature; - o Date: 6/6/2016 JUN 2016