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®6fT3rlfR-RrAN Isc. GR Job# 18200384 <br /> S WRCB,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 5450 Date of Testing: 2/7/2018 <br /> Facility Address: 16171N.Fremont. Stockton,CA 95203 <br /> Facility Contact: Daryl Lee Phone: 415.902.5089 <br /> Date Local Agency Was Notified of Testing: <br /> ame of Local Agency Inspector(ifpresent during testing): <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-R an Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.il 925-551-7555 <br /> Technician Conducting Test: David Rouse <br /> Credentials: CSLB Licensed Contractor <br /> License T e: ICC License Number: 220793 <br /> Manufacturer Trainine <br /> Manufacturer Component(s) <br /> Incon Test System Operation Hydrostatic Testing <br /> Phil-Tite Spill Containment <br /> O w Spill Containment <br /> ICC Technician UST Com onents <br /> 3.SUMMARY OF TEST RESULTS <br /> Components Pass Fail Not Repairs Not Repairs <br /> p Tested Made Components Pass Fail <br /> Tested Made <br /> UDC 3-4 X <br /> UCD 7-8 X <br /> 87 STP X <br /> 91 FILL X <br /> 87.2 a <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <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: �a� Date: 2/7/2018 <br />