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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 /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10146199 06/21/2022 <br /> Facility Name <br /> Costco Wholesale - STOCKTON - 0038 <br /> Facility Address City ZIP Code <br /> 1630 East Hammer Lane Stockton 95210 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Belshire Environmental 949 460-5200 <br /> Mailing Address <br /> 25971 Towne Centre Drive Foothill Ranch CA 92610 <br /> Service Technician Performing Test <br /> Moises Burcia a <br /> Contractor/Tank Tester License Number <br /> 808313 <br /> ICC Number ICC Expiration Date <br /> 02/20/2023 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> See Attached <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI - RP1200/Manufacturer Tanks <br /> PEI - RP1200/Manufacturer Piping <br /> PEI - RP1200 Containment Sumps <br /> 5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I 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. I understand <br /> that test procedures shall be made available upon request by the governing authority. <br /> Service chnician Signature Date Total # of Pages <br /> 06/21/2022 <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 />