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a6ITTLIR-RYAN INC. <br />SWRCB, January 2002 <br />GR Job # 20-643211 <br />Page 1 of 2 <br />Secondary Containment Testing Report Form <br />This form is intended for use by contractors performing periodic testing of LIST 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 (j applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Dart Container Corp. Date of Testing: 12/20/2016 <br />Facility Address: 1400 E. Victor Road <br />Facility Contact: RobertVer as Phone: 209-333-8088 <br />Date Local Agency Was Notified of Testing: <br />Name of Local Agency Inspector lifpresent during testing) : <br />2_ TESTING CONTRACTOR INFORMATION <br />Company Name: Gettler-Agan Inc., 6805 Sierra Court Suite G, Dublin, Ca. 94568 Ph.# 925-551-7555 <br />Technician Conducting Test: Elodio Sanchez <br />Credentials: CSLB Licensed Contractor <br />License Type: C57 B C61ID40 HAZ A C10 <br />License Number: 220793 <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Incon Test S stem O eration <br />Hydrostatic Testing <br />Phil-Tite <br />Spill Containment <br />O w <br />Spill Containment <br />ICC Technician <br />UST Components <br />3. SUMMARY OF TEST RESULTS <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 al a E D <br />To the best of my knowledge, the facts stated in this document are accurate and to fall compliq{ "rih <br />Technician's Signature: C—�4 Date: 12/2012016 DEC 2 6 2017 <br />ENVIRONMENTAL HEALTH <br />DEPARTMENT <br />