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I <br /> GfTT1fA-RYAN INC. <br /> qRiREGEUED <br /> SWRCB,January 2002 Q$a 212 0 4 <br /> Secondary Containment Testing Report ForIENVIRONMENTAL HEALTH <br /> This form is intended for use by contractors performing periodic testing of UST secondary containment <br /> appropriate pages of this form to report results for all components tested. The complete form, written test procedures, an <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 /> acili Name: Arco SS 5450 Date of Testin : 11/21/2016 <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 /> liName of Local Agency Inspector(if present during testing): <br /> 2.TESTING CONTRACTOR INFORMATION <br /> Company Name: Gettier-Ryan Inc.,6805 Sierra Court Suite G,Dublin,Ca.94568 Ph.#925-551-755.5 <br /> Technician Conducting Test: Elodio Sanchez <br /> Credentials: CSLB Licensed Contractor <br /> License T e: C57 B C61/D40 HAZ A('10 License Number: 220793 <br /> Manufacturer Training <br /> Manufacturer Component(s) <br /> Incon Test S •stem Operation Hydrostatic Testing <br /> Phil-Tate Spill Containment <br /> O w Spill Containment <br /> ICC Technician LIST Com onents <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 /> Dis 3/4 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: C—. Date: 11/21/2016 <br />