Laserfiche WebLink
GETTtiiR-RYAN INC. GR Job # 20-632266 <br />SWRCB, January 2006 <br />Spill Bucket Testing Report Form <br />This form is intended for use by contractors performing annual testing of UST spill containment structures. The Completed form and <br />printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency. <br />FAP1111TV TNIMRUATInN <br />Facility Name: Arco 2693 Date of TeTin—g: 1 20 <br />Facility Address: 3425 Tracy Blvd Tracy. CA <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: 8/18/2015 SEP 2 <br />Name 01 LOcalAgency Ingpeclor (71 present during testing): atinah Zareef <br />Ejcaa °r#.l r)C05 T'M1A17h1T <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Gett er- yan Inc -6805 Sierra CourtSuiteG, Dublin, Ca. 9 56 h.# . 5-551-7555 <br />Technician Conducting Test: Chris San Nicolas <br />Credentials: (I) CSLB Contractor ICC service Tech. SWRCB Tank Tester Other (Specify) <br />License Num er: 22 793 ICC TechNumber: 5296364 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Change in Reading (Rf-Ri): <br />0 <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or Criteria: <br />0 <br />0 <br />0 <br />0 <br />I�-rest Kesults: 11 X Pass Fail I Y Pass Fail I Pass Fail X; Pass Fail J1 <br />Comments - (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements <br />Technician's Signature: `"'� Date: 918/201.5 <br />(1) State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements <br />may be more stringent. <br />