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SWRCB, January 20020 <br /> uct- -r- � <br /> Secondary Containment Testing Report Form ENVIRONMENTAL HMTH <br /> This form is rote.ndee for use by cotrtraetor;s pelvo n ing periodic testing of US'T secondarycoillainine rt. vstenrs. IRPWRRWate <br /> pages of this form to report results for all domponerits tested. the cotxplefecl faun, tit itten test pYaced:lres, crl�rl ppij7tq�rts fioir� tests <br /> (if applicable), should.be proi)icled to.lie facil#y dwnerloperator for submittal to the local.regiddlory ageMcy. <br /> 1. FACILITY INFORMATION <br /> FacilityNante: Costco Wholesale-TRACY-0658 Date of Testing: 10/12/2017 <br /> Facility Address; 3250 W. GRANTLINL RD,TRACY,CA 95377 <br /> Facilitv Contact: Costco Wholesale Corporation Phone:(209)834-1247 <br /> Date:Local Agency Was Notified of`Testing: 10/12/2017 <br /> Name of Local Agency Inspector(ifprlesev7t during testing) <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Naive: Belshire Environmental Services, Inc. <br /> Technioian Conducting Test: Saul Gonzalez <br /> Credentials: ® CSLB.Licensed Contractor n SWRCB Licensed Tanlc Tester <br /> License Type'..A-General Pnginecring Contraetor License Number: 808313 <br /> Manufacturer.Training <br /> Manufacturer Cont onent(s) Date T.aKfift' Exides <br /> See Attached <br /> 3. SUMMARY OF TEST RESULTS <br /> Nat Repairs Not Repairs <br /> Component Pass Fail Testes! Made Component Pass Fail Not <br /> Made <br /> Tank Annulars d ❑ ❑ R1 ❑ Exern t from Testin - ❑ ❑ ❑ ❑ <br /> Continuously Monitored <br /> Secona Pie 7 R1 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> Pi2ing Sump 3 9 ❑ ❑ ❑ ❑ ❑ ❑ Cl <br /> UDC 6 ❑ © ❑ ❑ ❑ ❑ ❑ <br /> hill Sump d ❑ ❑ ❑ ❑ Exempt from Testing- ❑ ❑ ❑ ❑ <br /> Continuously Monitored <br /> S gill Bucket 8 ❑ © ❑ ❑ T1 VB,T2 FB,T2 VB failed ❑ ❑ ❑ ❑ <br /> .If hydrostatic testing iyz performed,describe what was done wide the Nvater after completion of tests; <br /> 0 Placed in drums left on site for proper disposition. <br /> Trams orted to next.site for use In additional testing, <br /> CERTIFICATION OF TECHNICIAN RE,SPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of 17Jy:kntnoledge,the fads statedin this document lire aecurate-wid ill full conrs�iliryrce ivitlr leggy«l rerltdremettts. <br /> Technician's Signature: z',.. :>�••• Date: 10112/2017 <br />