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SWRCB,January 2002 Page I of 3 <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 owner/operator for submittal to the local regulatory agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name:Circle K Date of Testing:10l18/2010 <br /> Facility Address:1403 Country Club Blvd-Stockton,CA 95240 <br /> Facility Contact:Site Attendant Phone:209-943-2082 <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name:Gettler-Ryan Inc <br /> Technician Conducting Test:C.Bishop <br /> Credentials: 9CSLB Licensed Contractor ❑SWRCB Licensed Tank Test4WAteTrainin&Expires <br /> License Type:A,B,C10,C57,D40,HAZ License Number:220793 <br /> _Manufacturer Training <br /> Manufacturer Component(s) <br /> Incon-Incon Sump Tester-11105/2012 <br /> Bravo Systems-Gold Certified-10/22/2012 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Component Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> Used Oil Bay 1 ❑ ❑ ® ❑ C1 ❑ ❑ <br /> Used Oil Bay 2 99 ❑ ❑ 29 ❑ ❑ 0 ❑ <br /> UDC 7/8 N 0 0 N ❑ ❑ ❑ ❑ <br /> 11 1 0 0 ❑ ❑ ❑ 0 0 <br /> 0 1 0 0 0 0 0 0 0 <br /> ❑ ❑ 0 Cl 0 ❑ ❑ ❑ <br /> 0 0 0 ❑ 0 ❑ 0 ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ ❑ Cl <br /> 0 ❑ ❑ ❑ 0 ❑ ❑ 0 <br /> ❑ 1 ❑ 0 ❑ 0 ❑ 0 ❑ <br /> 0 ❑ ❑ ❑ ❑ ❑ 0 ❑ <br /> ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ <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 document are accurate and in full compliance with legal requirements <br /> DignaW Signed by Chris Bishop <br /> DN:cn=Chris Bishop,o,ou, <br /> erna=gm int@grine.eom,a=US <br /> Technician's Signature: �" Date:2010.12.00 15:08:06-OnO* Date:10/18/2010 <br />