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GErrao-RrAv IWc. fR Job# 18200384 <br /> SWRCB,January 2002 Page 1 of 4 <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 complete 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: Arco 5450 Date of Testing: 2/7/2018 <br /> acili Address: 1617 W.Fremont. Stockton,CA 95203 <br /> acili Contact: Daryl Lee Phone: 415.902.5089 <br /> Pate Local Agency Was Notified of Testing: <br /> ,[Name of Local Agency In for(ifresent during testing) <br /> 2.TESTING CONTRACTOR INFORMATION <br /> E <br /> an Name: Gettier-R an Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.#925-551-755 ician Conductin Test: David Rouse rantials: CSLB Licensed Contractorse T ]CC License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) <br /> Incon Test System Operation Hydrostatic Testing V1 R C- <br /> hil-Tite Sill Containment E P- ,"JOPW Spill Containment <br /> ICC Technician UST Com nents <br /> 3.SUMMARY OF TEST RESULTS <br /> Components Pass Fail Not Repairs Components Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> UDC 34 X <br /> UCD 7-8 X. <br /> 87 STP X <br /> 91 FILL X <br /> 87.2 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the fads stated In this document are accurate and in full compliance with legal requirements <br /> Technician's Signature: 717 � �---- Date: 2/7/2018 <br />