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9255517899 Line 1 • 03:09:35 p.m. 01-04-2011 217 <br /> ®GETTLER-RYAN INC. Job# 20-563030 <br /> SWRCB,January 2002 Page 1 of 6 <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: PG&E Date of Testing: 12/7/2010 <br /> Facility Address: 4040 West Lane-Stockton,CA95204 <br /> Facility Contact: Alex Steele Phone: 209-337-8902 <br /> Date Local Agency Was Notified of Testing: 11/5/2010 <br /> Name of Local Agency Inspector(ifpresent during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6747 Sierra Court Suite J,Dublin,Cu.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Jose Carrasco <br /> Credentials: CSLB Licensed Contractor <br /> License Ty e: C57 B C61/1340 HAZ A C10 License Number: 220793 <br /> Manufacturer Trainin¢ <br /> Manufacturer Component(s) Date Training Expires <br /> lneon Test System Operations Hydrostatic Testing 12/1/2012 <br /> Phil-Tite Spill Containment 8/17/2012 <br /> OPW Spill Containment 4/8/2011 <br /> ICC Technician UST Components 1/8/2012 <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Components Pass Fail Tested Made Components Pass Fail Tested Made <br /> Secondary Pipe Testing x <br /> Piping Sums x <br /> Dispenser UDCs x <br /> Tank Annulars x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Water was left on site in 55 gallon drums. The drums were labeled with hazardous waste stickers. <br /> CERTFICATION 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 /> Technician's Signature: � Date: 12/7/2010 <br />