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9255517888 Une 1 ':19:32 08-20-2012 2/5 <br /> ®6lETT1ER-RYA N INc. GR Job# 20-581053 <br /> SW-RCB,January 2002 Page I of 2 <br /> Secondary Containment Testing Report Form <br /> This form is intended for use by contractors petforming 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: 11 est Valley Chevron Date of Testing: 6i28i2012 <br /> Facility Address: 2615 West Grantline Rd.,Traly,CA <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> Name of Local Agency Inspector(i resent during testing: <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc..6747 Siena Court Suite J,Dublin.Ca.94568 Ph.#925-551-7555 <br /> Technician Conductin Test: Chris Bishop <br /> Credentials: CSLB Licensed Contractor <br /> License'Ty e: C57 13 C6I/D40 t1AZ A C10 License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon"fest System Operation Hydrostatic Testing 11/5/2012 <br /> Phil-Tite Spill Containment 7/29/2012 <br /> Opw Spill Containment 6/24/2012 <br /> ICC'fechnician UST Components 5/18/2014 <br /> 3.SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Components Pass Fail Tested Made Components Pass Fail 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 /> Leff 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 fall compliance with legal requirements <br /> Technician's Signature: Date. 6128!2012 <br />