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REGEIVF . <br /> 6irTLER-RYAN INC. GR Job# 20-630774.1 <br /> JUN 0 2 2015 <br /> SWRCB,January 2002 Page 1 of' 3 <br /> ENVIRONMENTAL <br /> Secondary Containment Telling,WjWt 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 (f applicable), should be provided to the facility owner%operator for submittal to the local regulator), agency. <br /> 1. FACILITY INFORMATION <br /> Facility Name: West Valley Chevron Date of Testing: 5/26/2015 <br /> Facility Address: 2615W Grant Linc Road Trace <br /> Facility Contact: Phone: <br /> Date Local Agency Was Notified of Testing: <br /> ame of Local Agency Inspector(rf present during testing) Michelle Henry <br /> 2. TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettler-Ryan Inc.,6805 Sierra Court Suite G, Dublin,Ca.94568 Ph.#925-551_7555 <br /> Technician Conducting Test: Chris San Nicolas <br /> Credentials: ('SLB Licensed Contractor <br /> License Type: C57 B C61/1)40 HAL A C10 License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) Date Training Expires <br /> Incon Test System Operation Hydrostatic 1 esting 2/11/2015 <br /> Phil-Tito Spill Containment <br /> OpVs Spill C ontainment 10/54/2014 <br /> ICC Technician L ST Components 12/6/2014 <br /> 3.SUMMARY OF TEST RESULTS <br /> Components Pass Fail Not Repairs Components Pass Fail Not Repairs <br /> Tested Made Tested Made <br /> t:!)C 7-8 X <br /> N ent Sump X <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 <br /> stated in this document are accurate and in full compliance with legal requirements <br /> ='�i •' <br /> Technician's Signature: Date: 5/26/2015 <br />