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GfTTLfR-RYAN INC. f zs� J S ��- �R Job# 20-581053 <br /> SWRCB,January 2002 Page 1 of 2 <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: West Valley Chevron Date of Testing: 6/28/2012 <br /> Facility Address: 261.5 West Grantline Rd.,Tracy,CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> I[Name of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: -Gettler-Ryan Inc.;6747 Sierra Court Suite J,Dublin,Ca.94.568 Ph.#925-551-75.55 <br /> Technician Conducting Test: Chris Bishop <br /> Credentials: CSLB Licensed Contractor <br /> License Type: C57 B C61/D40 IIAZ A C10 License dumber: 220793 <br /> Manufacturer TraininE <br /> Manufacturer Component(s) Date Training Expires <br /> [neon Test System Operation Hydrostatic Testing 11/5/2012 <br /> Phil-Tite Spill Containment 7/29/2012 <br /> Opw Spill Containment 6/2412012 <br /> ICC Technician UST Components 5/18/2014 <br /> 3.SUMMARY OF TEST RESULTS <br /> Components Pass Fail Not Repairs Components Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> 87 STP x <br /> 91 STP x <br /> Diesel STP x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> Left 4 55 gal drums onsite with label. <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: 6/28/2012 <br />