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Appendix VII <br />Underground Storage Tank <br />Secondary Containment Testing Report Form <br />TYPE OF ACTION ❑ Installation 52 Repair ❑ 6 Month ❑ 36 Month <br />1. FACILITY INFORMATION <br />CERS ID <br />10146285 <br />Test Date <br />12/18/2023 <br />Facility Name <br />Costco 658 Tracy <br />Facility Address <br />3250 W Grantline Rd. <br />City Tracy <br />ZIP Code <br />95304 <br />2. SERVICE TECHNICIAN INFORMATION <br />Company Performing the Test <br />Jones Covey Group, Inc. <br />Phone <br />(209) 834-1247 <br />Mailing Address 9595 Lucas Ranch Rd. #100, Rancho Cucamonga, CA. 91730 <br />Service Technician Performing Test <br />Justin Zorn <br />Contractor/Tank Tester License Number <br />804431 A, B HAZ <br />ICC Number ICC - 9157862 <br />ICC Expiration Date <br />02/03/2025 <br />3. TRAINING AND CERTIFICATIONS <br />Manufacturer and Test Equipment Training Certifications <br />Expiration Date <br />Fiber Glass Systems NOV <br />05/22/2026 <br />4. TEST PROCEDURE INFORMATION <br />Test Procedures Used <br />Components Tested <br />PEI -1200 <br />87A Vent Secondary Line <br />5. CERTIFICATION BY SERVICE TECHNICIAN CONDUCTING TEST <br />I hereby certify that the secondary containment was tested in accordance with California <br />Code of Regulations, title 23, division 3, chapter 16, section 2637, that required supporting <br />documentation is attached, and all information contained herein is accurate. I understand <br />that test procedures shall be made available upon request by the governing authority. <br />Service Technician Signature <br />Date <br />12/18/2023 <br />Total # of Pages <br />17 <br />CERS = California Environmental Reporting System, ICC = International Code Council, <br />ID = Identification, NA = Not Applicable, UDC = Under -Dispenser Containment, <br />Page 1 of 5 <br />