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a6ETTLEURY0 INC. GR Job# 17205079 <br /> SWRCB,January 2002 Page of <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 2186 Date of Testing: 12/26/2017 <br /> Facility Address:3212 N.Califomia,Stockton CA 95204 <br /> Facility Contact: Daryl Lee Phone:415.902.5089 <br /> Date Local Agency Was Notified of Testing: <br /> ame of Local Agency Inspector(ifpresenl during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-R-an Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.##925-551-7555 <br /> Technician Conducting Test: <br /> Credentials: CSLB Licensed Contractor <br /> License T C57 B C61ID40 HA7,A CI0 License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s)) Date Training Expires <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Components Pass Fail Tested Made Components Pass Fail Tested 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 stated in s document are accurate and in full compliance with legal requirements <br /> Technician's Signature: e6A Date: 12/26/201 <br />