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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ® Installation ❑ Repair ❑ 6 Month ❑ 36 Month <br /> I . FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10146199 2/24/2021 <br /> Facility Name <br /> Costco #0038 <br /> Facility Address City ZIP Code <br /> 1630 E Hammer Lane Stockton <br /> 2 . SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Wa ne 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 C61 /D40 HAZ <br /> ICC Number ICC Expiration Date <br /> 5115738 12/3/2022 <br /> 3 . TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> Xerxes 12/27/2021 <br /> NOV/Smith 03/ 13/2021 <br /> Bravo 04/12/2022 <br /> 4 , TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI RP1200 Sumps <br /> PEI RP1200 <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 16, 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 1 ` Date Total # of Pages <br /> z ' N 2/24/2021 <br /> CERS = California Environmental Reporting System , ICC = International Code Council , <br /> ID = Identification , NA = Not Applicable , UDC = Under- Dispenser Containment , <br /> Pagel of 5 <br />