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Appendix VII <br /> Underground Storage Tank <br /> Secondary Containment Testing Report Form <br /> TYPE OF ACTION ❑ Installation ❑ Repair 52 6 Month ❑ 36 Month <br /> 1. FACILITY INFORMATION <br /> CERS ID Test Date <br /> 10146285 07/17/2023 <br /> Facility Name <br /> Costco 658 Tracy <br /> Facility Address City Tracy ZIP Code <br /> 3250 W Grantline Rd. 95304 <br /> 2. SERVICE TECHNICIAN INFORMATION <br /> Company Performing the Test Phone <br /> Jones Covey Group, Inc. (888)972-7581 <br /> Mailing Address 9595 Lucas Ranch Road #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 ICC Expiration Date <br /> 02/03/2025 <br /> 3. TRAINING AND CERTIFICATIONS <br /> Manufacturer and Test Equipment Training Certifications Expiration Date <br /> NOV Fiber Glass Systems 05/22/2026 <br /> 4. TEST PROCEDURE INFORMATION <br /> Test Procedures Used Components Tested <br /> PEI-1200 5psi for 1 hour 87A Product Line/87B Product Line/87C Product Line <br /> PEI-1200 5psi for 1 hour 87A Vent Line/87B Vent Line/87C Vent Line <br /> PEI-1200 5psi for 1 hour 87A-87B Siphon Line/87B -87C Siphon Line/Vapor Return <br /> PEI-1200 5psi for 1 hour 87A Additive Line/87B Additive Line/87C Additive 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 Date Total # of Pages <br /> 07/17/2023 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 />