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Appendix 1111 <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair ❑ 6 Month 0 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10749253 06/03/2025 <br /> Facility Name <br /> Costco Wholesale - STOCKTON - 0038 <br /> Facility Address City ZIP Code <br /> 1630 East Hammer Lane . Stockton 195210 <br /> . 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 Burciaga <br /> ontractorfTank Tester License Number <br /> 808313 <br /> ICC Number ICC Expiration Date <br /> 9940317 10/05/2025 <br /> . TRAINING AND CERTIFICATION <br /> ianufacturer and Test Equ/pment Train/rig C e r6fica tio ns Expiration Date <br /> See Attached <br /> 1T4. TEST PROCEDURE INF0RMATI N <br /> Test Procedures Used Components Tested <br /> PEI - RP1200/Manufacturer Tanks <br /> PEI - RP1200/Manufacturer Piping <br /> PEI - RP1200 Containment Sumps <br /> S. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br /> I hereby certify that the secondary corrtaininent was tested in accordanca with CaWom a <br /> Code of Regulations, title 23, division 3, chapter 16, section 2637 chat required suppor#!ng <br /> docurrrenfaclorr is attached, and aH information contained herein is accurate. 1 understand <br /> that test procedures sha/I be rrrade available upon reques t by the grovemingr authority. <br /> Servicechnician Signature Date Total # of Pages <br /> 06/03/2025 <br /> CERS = California Environmental Reporting System. ICC = International Code Council, <br /> ID = Identification. NA = blot Applicable, UDO = Under-Dispenser Containment, <br /> Page 1 of 4 <br />