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RECEIVED <br /> �GETTLER-RYAN INC. sEP z s 2016 (�L Job# 20-641304.1 - 2 <br /> SWRCB,January 2002 Page 1 of 4 <br /> ,ENVIROWENTAL HEALTH <br /> Secondary Containm@ WgEReport 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 SS 2186 Date of Testing: 8/24/201.6 <br /> Facility Address: 3212 N California Avenue,Stockton,CA <br /> Facility Contact: Sarah Samuels Phone: 360-526-3917 <br /> Date Local Agency Was Notified of Testing: <br /> 1INarne of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> 'Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G, Dublin,<:a.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Elodio Sanchez <br /> Credentials: CSLB Licensed Contractor <br /> License Ty e: C57 B C61/1)40 1-IAZ A CIO License Number: 220793 <br /> Manufacturer Trainin>: <br /> Manufacturer Component(s) <br /> Incon Test System Operation hydrostatic Testing <br /> Phil-rite Spill Containment <br /> O w Spill Containment <br /> ICC Technician IST Components <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Components Pass Fait Tested Made Components Pass Fail <br /> Tested Made <br /> 87-2 STP x <br /> Dis 5/6 x <br /> 87-2 87-1 Siphon x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> 5 Drums left on site. <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: !f—�'G- �--✓1 Date: 8124/2016 <br />