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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 (f applicable), should be provided to the facility owner/operator 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 0 2 . 5 0 8 9 <br /> Date Local Agency Was Notified of Testing : <br /> Name of Local Agency Inspector (i(present during testing) : <br /> 2. TESTING CONTRACTOR INFORMATION <br /> CompanyName : Gettler Ran 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 93 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) Date Training Expires <br /> Incon TS - STS 09 / 2018 <br /> 3. SUMMARY OF TEST RESULTS <br /> Component Pass Fail Not Repairs Not Repairs <br /> p Tested Made Component Pass Fail Tested Made <br /> 87 Slave STP 0 ❑ ❑ 0 ❑ ❑ 0 a <br /> 87 Master STP 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> 87 Siphon STP 0 ❑ ❑ ❑ 0 a 0 a <br /> 91 STP 0 ❑ ❑ ❑ ❑ ❑ ❑ 0 <br /> o ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ ❑ ❑ ❑ a ❑ ❑ a <br /> ❑ o ❑ ❑ a a a ❑ <br /> ❑ a ❑ ❑ ❑ a ❑ a <br /> ❑ ❑ ❑ ❑ a ❑ o ❑ <br /> 0000 0 a ❑ ❑ <br /> ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ <br /> ❑ 0 ❑ ❑ ❑ 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 ment are accurate and in full compliance with legal requirements <br /> Technician ' s Signature : Date: 03 / 27 / 20108 <br />