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v F,n <br /> R E C,F. <br /> ®GETTIER-RYAN IVC. JAS 9 8 2016 GR Job# 17205079 <br /> SWRCB,January 2002 <br /> ENVIRONMENTAL HEALP-1 Page of <br /> nF2AOTMENT <br /> Secondary Containmenffisting 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 2186 Date of Testing:12/26/2017 <br /> Facility Address:3212 N.California,Stockton CA 95204 <br /> Facility Contact: Darvl Lee Phone:415.902.5089 <br /> Date Local Agency Was Notified of Testing: <br /> ame of Local Agency Inspector(if resent during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> ompany Name: Gettler-R an Inc..6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.ii 925-551-7555 <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor <br /> icense T C57 B C61/D40 R.A.Z.A C10 License Number: 220793 <br /> Manufacturer Trainine <br /> Manufacturer Com nen s Date Training Expires <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Repairs <br /> Components Paas Fail Tested Made Components Paas Fail .rhe Made <br /> Diesel 5/6 X <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> CERTFICATION OF TECHNIC N RESPONSIBLE FOR CONDUCTING THIS TESTING <br /> To the best of my knowledge, the facts staled in document are accurate and in full compliance with legal requirements <br /> Technician's Signature: � Date: 12126/201 <br />