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9255517888 Line 12:48:04 08-12-2013 2/4 <br />6ETTIER-RYA N INC. Job # 20-591407,1 <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. FArnxry INvnRMATTnN <br />Facility Name: Arco 5450 Date of Testing: 8/9/2013 <br />Facility Address: 1617 W Fremont St.. Stockton, CA <br />Facility Contact: Phone: <br />Date Local Agency Was Notified of Testing: 7/31/2013 <br />,jName of Local Agency Inspector (if present dur!ng testing) : <br />2_ TESTING CONTRACTOR TNVORMATinN <br />Company Name: Gettler-I2,yan Inc.. 6747 Sierra Court Suite J, Dublin, Ca. 94568 Ph.# 925-551-7555 <br />Technician Conducting Test: Elodio Sanchez <br />Credentials: CSLB Licensed Contractor <br />License Type: C5713 C61/D40 IIAI A CIO <br />License Number: 220793 <br />Manufacturer <br />Manufacturer Training <br />Component(s) <br />Date Training Expires <br />[neon Test System Operation <br />Hydrostatic Testing <br />6/25/2014 <br />Phil -rite <br />Spill Containment <br />7/30/2015 <br />Opw <br />Spill Containment <br />5/6/2015 <br />[CC Technician <br />UST Com onentc <br />9/13/2013 <br />3. SUMMARY OF TEST RESULTS <br />®® <br />If hydrostatic performed, •' •-what wasdone with the water after completion of tests: <br />CERTFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />To the best of my knowledge, the fads stated in this document are accurate and in full compliance with legal requirements <br />Technician's Signature: 'C--�' �`�--�-� 3 Date: 8/9/2013 <br />Received Time Aug. 12. 2013 12:41PM No. 3856 <br />