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SWRCIJ,January 2002 Page 1. <br /> Second Containment Testing Rept Form <br /> This form is intended for use by contractors performing periodic testing of(IST secondary containment systems. Use the <br /> appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and <br /> printouts from tests(f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO 1031 1 Datc of Testing: 01/15/2009 <br /> Facility Address: 2440 DANIELS STREET MANTECA, CA, 95336 <br /> Facility Contact: MANAGER Phone: (2 0 9) 823-0591 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: TANKNOLOGY, INC. <br /> Technician Conducting Test: BRIAN MCPHEELY <br /> Credentials: CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester <br /> License Type: License Number: 8010965-UT <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repair <br /> Component Pass Fail Tested Made Component Pass Fail Tested <br /> Spill Box 1 UNL FILL E ❑ D D O El Ej E <br /> Spill Sox 2 UNL FILL ❑ ❑ El El <br /> Spill Box 3 PRE FILL ❑ ❑ El L] L <br /> El LI ❑ D El El <br /> 0 E El E ❑ ❑ L <br /> ❑ Q ❑ L] El ❑ <br /> El El 171 E:1 Il El M <br /> El El El Il L <br /> El- <br /> El ❑ D 0 El 0 ❑ ❑ <br /> El L ❑ El El <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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: 23 <br /> Date: 01/15/2009 <br />