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Secondary Containment Testing Report 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 completed form, written test procedures, and <br /> printouts from tests(if applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> t. FACILITY INFORMATION <br /> Facility Name: COSTCO#0658 Date of Testing: 04/11/18 &05/15/18 <br /> Facility Address: 3250 W Grant Line Rd, Tracy, CA 95304 <br /> Facility Contact: I Phone ❑Initial ✓❑Repair Test <br /> Date Local Agency Was Notified of Testing: 04/03/18 &05/02/18 ❑6 Month ❑Other <br /> Name of local Agency Inspector(ifpresent during testing): Betty Ho/Elena K.Monzo ❑Triennial <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry Inc <br /> Technician Conducting Test: Nick Harvey ICC#5115738 <br /> Credentials: p CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester m ICC UST Service Technician <br /> License Type: A C21 C10 B C61/D40 HAz C34 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 /> UDC 1/2 m ❑ ❑ © ❑ ❑ ❑ ❑ <br /> UDC 3/4 © ❑ ❑ © ❑ ❑ ❑ ❑ <br /> UDC 7/8 0 ❑ ❑ © ❑ ❑ ❑ ❑ <br /> UDC 9/10 © ❑ ❑ © ❑ ❑ ❑ ❑ <br /> 87 T1 Vapor m ❑ ❑ © ❑ ❑ ❑ ❑ <br /> 87 T2 Fill © ❑ ❑ © ❑ ❑ ❑ ❑ <br /> 87 T2 Vapor © ❑ ❑ © ❑ ❑ ❑ ❑ <br /> ❑ 11 ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ 1 ❑ 1 ❑ 1 1 ❑ ❑ I ❑ ❑ <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 Signature: � `.' C � Date: 04/11/18 &05/15/18 <br />