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• • Page I of 3 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST 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(if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: COSTCO#038 1 Date of Testing: 1/30/2014 <br /> Facility Address: 1616 E.HAMMER LANE, STOCKTON,CA 95210 <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing : 1/21/2014 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2014 <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Wayne Perry,Incorporated <br /> Technician Conducting Test: NICK HARVEY ICC#5115738 MrALTH DEPARTMENT <br /> Credentials: X CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: A,HAZ,C21,C10,B,C61,D40 I License Number: 300345 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Furnished on request <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> P Tested Made Tested Made <br /> 87 Prod Sec Line 10 [Ell <br /> UDC 7/8 ® Li ❑ ® ❑ ❑ ❑ ❑ <br /> UDC 9/10 ® ❑ ® ❑ 1-1 ❑ El <br /> UDC 11/12 ® ❑ ❑ ® ❑ El ❑ <br /> ❑ El El ❑ ❑ El ❑ <br /> ❑ ❑ ❑ ❑El El El El tL] E] <br /> ED <br /> ❑ Ll :1 L-1 EJ ❑ El— <br /> Li <br /> ❑ ❑ ❑ ❑ ❑ ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> No drums were left on site <br /> CERTIFICATI OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledg ,t e facts stated in this current are accurate and in full compliance with legal requirements <br /> Technician's Signature Date:-1/302014 <br />