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SWRCB, January 2002 Page 5 of 17 Secondary Containment Testing Report Form This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the appropriate pages of this form to report results for all components tested. The completed form, written test procedures, and printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: Costco 658 Tracy Date of Testing: 07/17/2023 Facility Address: 3250 W Grantline Rd. Facility Contact: Manager Phone: (209) 834-1247 Date Local Agency Was Notified of Testing: Name of Local Agency Inspector (if present during testing): N/A 2. TESTING CONTRACTOR INFORMATION Company Name: Jones Covey Group, Inc. Pass Technician Conducting Test: Justin Zorn Not Tested Credentials: 101CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: A, B HAZ License Number: 804431 Manufacturer Manufacturer Training Component(s) Date Training Expires Fiber Glass Systems 05/22/2026 ❑ ❑ ❑ 87B Product Line [? ❑ 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made 87A Product Line IV ❑ ❑ ❑ 87B Product Line [? ❑ ❑ ❑ 87C Product Line [V ❑ ❑ ❑ 87A Vent Line ❑ [? ❑ ❑ 87B Vent Line [i? ❑ ❑ ❑ 87C Vent Line 5? ❑ ❑ ❑ 87A - 87B Siphon Line C►? I ❑ ❑ ❑ 87B - 87C Siphon Line IV ❑ ❑ ❑ Vapor Return Line ❑ [9 ❑ ❑ 87A Additive Line [i? ❑ ❑ ❑ 87B Additive Line J' ❑ ❑ ❑ 87C Additive Line 5? ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑❑ ❑ El 11 ❑ El Li 11112 ❑ I ❑ ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date: 07/17/2023