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0 • <br /> SWRCB,January 2002 GR Job# 18200927.1 Page t of 2 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment systems. Use the <br /> appropriate pages of this form to report resultsfor all components tested. The completed form,written test procedures,and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Arco 02093 Date of Testing:03/27/2018 <br /> Facility Address:3425 N. Tracy Blvd <br /> Facility Contact:Daryl Lee Phone:415 .9 02 .5089 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(f present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Gettler Ryan Inc. <br /> Technician Conducting Test:David Rouse <br /> Credentials: ❑CSLB Licensed Contractor ❑SWRCB Licensed Tank Tester <br /> License Type: License Number:2 2 0 7 9 3 <br /> Manufacturer Trainine <br /> Manufacturer Component(s)) Date Training Expires <br /> Incon TS-ST5 09/2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested :Made <br /> 87 Slave STP 0 a 0 ❑ 87-1 Siphon Secondary 0 a o a <br /> 87 Master STP 0 ❑ ❑ ❑ 87-2 siphon Secondary 0 0 0 0 <br /> 87 Siphon STP a 0 ❑ 1 0 a ❑ 1 ❑ ❑ <br /> 91 STP 0 a ❑ ❑ a ❑ ❑ a <br /> a a a 0 0 a a <br /> a a a ❑ a a a a <br /> ❑ a a 0 0 a ❑ <br /> ❑ ❑ a ❑ a a ❑ a <br /> a a ❑ 0 a a <br /> a a 0 a s a a <br /> 0 a ❑ a ❑ a 0 a <br /> o I ❑ ❑ ❑ a a a ❑ <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this meat are accurate and in fall compliance with legal requirements <br /> Technician's Signature: Date: 03/27/20108 <br />