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SWRCI ,January 2002 0 Page 1. <br /> Secondary Containment Testing Repo t 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(f applicable),should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO LODI Date of Testing: 05/27/2011 <br /> Facility Address: 322 E. HARNEY LANE LODI, CA, 95240 <br /> Facility Contact: MANAGER Phone: (2 0 9) 964-0180 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): RAY VON FLUE <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: KRISTOPHER BELL <br /> Credentials: a CSLB Licensed Contractor SWRCB Licensed Tank Tester <br /> License Type: CONTRACTOR I License Number: 743160 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> PHILTITE INSTALATION <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested Made <br /> Spill Box 1 REG FILL P-711 <br /> ❑ ❑ ❑ ❑ ❑ El <br /> Spill Box 1 REG VAPOR x ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 REG FILL FRI ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 2 REG VAPOR X ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Spill Box 3 PRE FILL X ❑ ❑ ❑ ❑ ❑ ❑ E <br /> Spill Box 3 PRE VAPOR E ❑ ❑ ❑ ❑ ❑ E ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ El ❑ ❑ ❑ ❑ ❑ <br /> o ❑ ❑ a ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ a F-1 El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> JARROD TOOK WATER <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: y Date: 05/27/2011 <br />