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0 0 <br />SWRCB, January 2006 <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 />Facility Name: Hammer Lane Oil Date of Testing: 06/21/2012 <br />Facility Address: 3304 W. Hammer Lane, Stockton, Ca. 95619 <br />Facility Contact: Mike I Phone: (209) 478-9293 <br />Date Local Agency Was Notified of Testing: oto -OQ <br />Name of Local Agency Inspector (ifpresent during testing): Garrett Backus <br />2. TESTING CONTRACTOR INFORMATION <br />Company Name: Reliable Petroleum Services, Inc. <br />Technician Conducting Test: Guadalupe Sanchez <br />Credentials': x CSLB Contractor x ICC Service Tech. ❑ SWRCB Tank Tester ❑ Other (Spec) <br />License Number(s): 883706 5250451 -UT <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution:N/A <br />=7777 <br />., . . <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />I Tl: 87 Fill <br />2 T2: 91 Fill <br />3 T3: Diesel Fill <br />4 T4: <br />Bucket Installation Type: <br />x Direct Bury <br />❑ Contained in Sump <br />x Direct Bury <br />❑ Contained in Sump <br />x Direct Bury <br />❑ Contained in Sump <br />Direct Bury <br />❑ Contained in Sum <br />Bucket Diameter: <br />12" <br />12" <br />12" <br />Bucket Depth: <br />12" <br />12" <br />14" <br />Wait time between applying <br />vacuum/water and start of test: <br />1 minute <br />1 minute <br />1 minute <br />Test Start Time (Ti): <br />10:00 a.m. <br />10:01 a.m. <br />10:02 a.m. <br />Initial Reading (RI): <br />11" <br />11" <br />13" <br />Test End Time (TF): <br />11:00 a.m. <br />11:01 a.m. <br />11:02 a.m. <br />Final Reading (RF): <br />11" <br />11" <br />13" <br />Test Duration (TF — TI): <br />1 hr <br />lhr <br />1 hr <br />Change in Reading (RF - RI): <br />0 <br />0 <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />1/16" <br />1/16" <br />TestResult: <br />I x Pass ❑ Fail <br />x Pass ❑ Fail <br />x Pass ❑ Fail <br />Pass ® Fail <br />Comments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby cert4o that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: Date 06/21/2012 <br />' 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 />