Laserfiche WebLink
(I <br /> ' GFT TL FR-RYAN INC. R E C E � P OR Job# 20-640550.1 <br /> SWRCB,January 2002 JAN 0 6 2017 Page I of 4 <br /> E RONMENTAL HEALTH <br /> Secondary Containmed' eort For <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: Arco SS 5450 Date of Testing: 11121/2016 <br /> Facility Address: 1617 W.Fremont,Stockton,CA <br /> Facility Contact: Wade Melton Phone: 360-594-7978 <br /> Date Local Agency Was Notified of Testing: <br /> ame of Local Agency Inspector(f present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Cam an Name: Gettler-Ryan[tic..6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.#925-551-7555 <br /> Technician Conducting Test: Elodio Sanchez <br /> Credentials: CSLB Licensed Contractor <br /> License Type: C57 B C61/1340 HAZ A C10 License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) <br /> Incon Test Svstem Operation Hydrostatic Testing <br /> Phil-rite Spill Containment <br /> JOEW Spill Containment <br /> [CC Technician L!ST Components <br /> 3. SUMMARY OF TEST RESULTS <br /> Not Repairs Not Repairs <br /> Components Pass Fail Tested Made Components Pass Fail Tested Made <br /> 87-1 STP x <br /> 91 Fill STP x <br /> 87-2 Fill Sump x <br /> Disp 314 x <br /> Dis 7/8 x <br /> If hydrostatic testing was performed,describe what was done with the water after completion of tests: <br /> (8)55 gallon drums left on site. <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: 11/2112016 <br />