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UNDERGROUND STORAGE TANK <br /> SECONDARY CONTAINMENT TESTING REPORT FORM (Page 1 of 6) <br /> Type of Action 36 Month Test <br /> I . FACILITY INFORMATION <br /> CERS ID Date of Secondary Containment Test <br /> 10146285 9/24 /2020 <br /> Business Name (Same as Facility Name or DBA-Doing Business As) <br /> Costco Wholesale - TRACY - 0658 <br /> Business Site Address City ZIP Code <br /> 3250 W . Grantline Rd Tracy 95377 <br /> II . UNDERGROUND STORAGE TANK SERVICE TECHNICIAN INFORMATION <br /> Name of UST Service Technician Performing the Test (Print as shown on the /CC Certification) Phone # <br /> Jeff Badders ( 949 ) 460 - 5200 <br /> Contractor / Tank Tester License # ICC Certification # ICC Certification Expiration Date <br /> 808313 5252456 5/29 /2021 <br /> III . SUMMARY OF SECONDARY CONTAINMENT TESTING RESULTS <br /> TANK ID : (Bytank number, stored product, etc.) A T1 87 B T2 87 C T3 91 D T4 Additive <br /> Tank Containment <br /> Tightness Test Result Exempt Exempt Exempt Exempt <br /> Product Piping Containment <br /> Tightness Test Result Pass Pass Fail <br /> Communication Test Result Pass Pass Fail <br /> Remote Fill Piping Containment <br /> Tightness Test Result <br /> Communication Test Result <br /> Vent Piping Containment <br /> Tightness Test Result <br /> Communication Test Result <br /> Vapor Recovery Piping Containment <br /> Tightness Test Result Pass Pass Pass <br /> Communication Test Result Pass Pass Pass <br /> Turbine / Product Piping Sump <br /> Tightness Test Result Pass Pass Pass <br /> Fill Riser Sump <br /> Tightness Test Result <br /> VENT I TRANSITION SUMP ID : a b C d <br /> Tightness Test Result <br /> UDC ID : 1 1 /2 2 3/4 3 5/6 4 7/8 <br /> Tightness Test Result Fail Fail Pass Pass <br /> UDC ID : 5 9 / 10 6 11 / 12 7 8 <br /> Tightness Test Result Pass Fail <br /> UDC ID : 9 10 11 12 <br /> Tightness Test Result <br /> All Items marked "Fall' or "NA " must be explained In their respective "COMMENTS " section. <br /> IV. CERTIFICATION BY UST SERVICE TECHNICIAN CONDUCTING THIS TESTING <br /> I hereby certify that the secondary containment was tested in accordance with California Code of Regulations , Title 23, Division <br /> 3 , Chapter 16, Section 2637 and all the information contained herein is accurate. <br /> UST Service Technician Signature <br /> j. <br /> i <br /> i <br /> CERS = Califomia Environmental Reporting System, ID = tdentiGcation, UST = Underground Storage Tank, ICC = International Code Council, NA = Not Applicable, UDC = Under- <br />] Dispenser Containment <br />