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UNDERGROUND STORAGE TANK SECONDARY CONTAINMENT TESTING REPORT FORM (Paget of 6) Type of Action ❑Installation Test ❑Repair Test E Six Month Test ❑36 Month Test I. FACILITY INFORMATION CERS ID Date of Secondary Containment Test 10146285 1 11/15/18 Business Name(Same as Facility Name or DBA-Doing Business As) Costco #0658 Business Site Address city ZIP Code 3250 W Grant Line Rd I Tracy 95304 II. UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION Name of UST Service Technician Performing the Test(Print as shown on the ICC Certification.) Phone# Nick Harvey (714)826 -0352 Ext. Contractor/Tank Tesler License# ICC Certification# ICC Certification Expiration Date 300345 A B C61/D40 HAZ 5115738 02!13/2019 III. SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS Tank ID:(By tank number,stored product,etc.) A B C D Tank Containment Tightness Test Result ❑Pass ❑Fail ❑ NA ❑ Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑ Pass ❑Fail ❑NA Product Piping Containment Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑ Fail ❑NA Remote Fill Piping Containment Tightness Test Result ❑Pass ❑ Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Vent Piping Containment Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA Vapor Recovery Piping Containment Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA Communication Test Result ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA Turbine I Product Piping Sump Tightness Test Result ❑Pass ❑Fail E NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail Z NA ❑ Pass ❑Fail Z NA Fill Riser Sump Tightness Test Result ❑Pass ❑Fail Z NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail Z NA ❑Pass ❑Fail E NA Vent I Transition Sump ID: a b Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA UDC ID: 11/2 3/4 7/8 9/10 Tightness Test Result Z Pass ❑Fail ❑NA Z Pass ❑Fail ❑NA Z Pass ❑Fail ❑NA E Pass ❑Fail ❑NA UDC ID: 5 6 Tightness Test Result ❑Pass ❑Fail ❑ NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA UDC ID: 9 10 11 12 Tightness Test Result ❑Pass ❑Fail ❑NA ❑Pass ❑ Fail ❑NA ❑Pass ❑Fail ❑NA ❑Pass ❑Fail ❑NA All items marked"Fail"or"N/A"must be explained in their respective"COMMENTS"section. IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING I hereby certify that the secondary containment was tested in accordance with California Code of Regulations,title 23, division 3,chapter 16,section 2637 and all the information contained herein is accurate. UST Service Technician Signature 1f_` A nia CERS=CaliforEnvironmental Reporting System,ID=Identification,UST=Underground storage tank,ICC=lntemadonal Code Council, NA=Not applicable,UDC=Under-dispenser containment