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Page 1 of 2 <br /> Sump & UDC Double Wall Testing Report Form <br /> 1. FACILITY INFORMATION <br /> Facility Name: Costco 658 Tracy Date of Testing: 01/04/2024 <br /> Facility Address: 3250 W. Grant Line Road <br /> Facility Contact: Eddie Phone: (209)834-1247 <br /> Date Local Agency Was Notified of Testing : 01/02/2024 <br /> Name of Local Agency Inspector(fpresent during testing): Kristina-San Joaquin County <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Jones Covey Group, Inc. <br /> Technician Conducting Test: Shawn Rodriguez <br /> Credentials: 1VCSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: A, B and Haz License Number: 804431 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Bravo National Certification#2021-2929435 Exp:12/01/2026 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 23/24 PressureNacuum Test [V ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> N/A <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: �' Date:01/04/2024 <br />