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Appendix V![ <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ® 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10146199 7/30/2021 <br /> Facility Name <br /> Costco #0038 <br /> Facility Address City ZIP Code <br /> 1630 E Hammer Lane Stockton 95210 <br /> 2. SERVICE.TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Wayne Perry, Inc. 714.826-0352 <br /> Mailing Address <br /> 8281 Commonwealth Avenue Buena Park, CA 90621 <br /> Service Technician Performing Test <br /> Nick Harvey <br /> Contractor/Tank Tester License Number <br /> 300345 A B C611D40 HAZ <br /> ICC Number ICC Expiration Date <br /> 5115738 12!312022 <br /> 3. TRAINING AND..CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Fastech ELDS Testing Computer 3!412022 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI RP1200 Secondary Lines <br /> PEI RP1200 Sumps <br /> PEI RP1200 <br /> PEI RP1200 <br /> 5. CERTIFICATION BY SERVICE'TECHNICIAN CONDUCTING TEST - <br /> 1 hereby certify that the secondary containment was tested in accordance with California <br /> Code of Regulations, title 23, division 3, chapter 96, section 2637; that required supporting <br /> documentation is attached; and all information contained herein is accurate. 1 understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service Technician Signature p Date Total # of Pages <br /> r 7/30/2021 <br /> CERS = California Environmental Reporting System, ICC = International Code Council, <br /> ID = Identification, NA = Not Applicable, UDC = Under-Dispenser Containment, <br /> Page 1 of 5 <br />