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swltcB,January 2002 SEPT 4 PF— Secondary Containment Testing Report Form 71" This form is intended for use by contractors performing periodic testing of UST seconday containment systems. `bse Ilse appropriate pages of thisfornt to report results for all components tested The completed form, written test procedures, and printouts from tests (ifapplicnble), should be provided to the facility owner/operator jar submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Costco Wholesale-STOCKTON-0038 Date of Testing:8/31/2016 Facility Address: 1616 EAST HAMMER LANE,STOCKTON,CA 95210 Facility Contact: Wierderholt,Michael Phone:(209)475-9180 Date Local Agency Was Notified of Testing: 8/31/2016 Name of Local Agency Inspector(ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name:Belshire Environmental Services,Inc. Technician Conducting Test:Saul Gonzalez _ Credentials: ® CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester License Type:A-General Engineering Contractor License Number:808313 Manufacturer Training Manufacturer Component(s) Date Training Expires See Attached 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Repairs Component Pass Fall Not Repairs Tested Made Tested Made Tank Armulars 3 ❑ ❑ © ❑ Exempt from Testing- ❑ ❑ ❑ ❑ Continuously Monitored Secondary Pie 6 p ❑ ❑ ❑ ❑ ❑ ❑ ❑ Piping Sump 3 © 10 ❑ ❑ ❑ ❑ ❑ ❑ UDC 6 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ Fill Sump 3 ❑ ❑ © ❑ Exempt from Testing- ❑ ❑ ❑ ❑ Continuously Monitored Spill Bucket 8 © ❑ ❑ ❑ ❑ ❑ ❑ ❑ If hydrostatic testing was performed,describe what was done with the water after completion of tests: ❑ Placed in drums left on site for proper disposition. 0 Transported to next site for use in additional testing. CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge,the fads stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 8/31/2016