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00 <br /> 6['TTLER-RYAN INC. vR ,Job# 20-641304.1 <br /> c <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 SS 2186 Date of Testing: 8/24/2016 <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"resting: <br /> Name of Local Agency Inspector(fpresent during testing) <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Siena Court Suite G, Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Elodio Sanchez <br /> Credentials CSLB Licensed Contractor p A. A <br /> License Type: C57 B C61/D40 HAI.A CIO O License Number: 220793 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) <br /> Ok- <br /> Beon Test System Operation Hydrostatic Testing <br /> Phil-Tito Spill Containment <br /> JOPW Spill Containment <br /> ICC Technician UST Components <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Components Pass Fail rested Made Components Pass Fail Tested Made <br /> 87-2 STP x <br /> Disp 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: ��---'� Date: 8/24/2016 <br />