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0 0 <br /> SWRCB,January 2002 GR Job# 18200927.1 Page 1 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 results for all components tested The completed form,written test procedures,and <br /> printouts from tests(if applicable),should be provided to the facility ownerloperatorfor submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facili!Z Name:Arco 02093 Date of Testing:03/27/2 018 <br /> -Facility Address:3425 N. Trac Blvd <br /> -Facility Contact:DaKyl Lee Phone:415 . 902 .5 0 8 9 <br /> Date Local Agency Was Notified of Testing: <br /> rName of Local Agency Inspector(if present during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> -Com p!gName:Gettler Ran Inc. <br /> -Technician Conducting Test:David Rouse <br /> Credentials: OCSLB Licensed Contractor []SWRCB Licensed Tank Tester <br /> License Type: License Number:2 2 0 7 9 3 <br /> L4anda <br /> Manufacturer Component(s) Date Training L)ipires <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 a 0 0 87-1 Siphon Secondary <br /> 87 Master STP E) [1 0 0 87-2 siphon secondary E) [1 0 a <br /> 87 Si hon STP ❑ a 0 1 0 0 a 11 11 <br /> 91 STP a 0 0 ❑ a a 11 <br /> ❑ a a 0 ❑ 11 a 13 <br /> ❑ a 0 0 ❑ 11 a a <br /> a 0 0 0 a a a <br /> a a 0 0 a a a a <br /> a a 0 0 a11 a I a <br /> a a 0 0 ❑ a a a <br /> a a 0 0 a 0 a <br /> ❑ a 0 0 0 a a a <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CER CATION OF TECHNIC LAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge,the facts stated in this <br /> rate and in full ca Mance with legal requirements <br /> 10 <br /> -4 <br /> Technician's Signature: d'_1 Date:03/27/20108 <br /> #14V <br />