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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 I Date of Testing: 06/22/2011 <br />Facility Address: 3304 W. Hammer Lane, Stockton, Ca. 95619 <br />Facility Contact: Mike Phone: (209) 478-9293 <br />Date Local Agency Was Notified of Testing: U % -)o -1/ <br />Name of Local Agency Inspector (if present 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 (Specify) <br />License Number(s): 883706 5250451 -UT <br />3. SPILL BUCKET TESTING INFORMATION <br />Test Method Used: xHydrostatic ❑ Vacuum ❑ Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution:N/A <br />,,ti.,.. - .. . v .;:> .... <br />Identify Spill Bucket (By Tank 1 Tl: 87 Fill <br />Number, Stored Product, etc. <br />2 T2: 91 Fill <br />3 T3: Diesel Fill <br />4 T4: <br />Bucket Installation Type: 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: 12" <br />12" <br />12" <br />Bucket Depth. 12" <br />12" <br />133/4" <br />Wait time between applying 1 minute <br />vacuum/water and start of test: <br />1 minute <br />1 minute <br />Test Start Time (TO: 09:04 a.m. <br />09:04 am. <br />09:04 a.m. <br />Initial Reading (RI): 11 '/4" <br />11 '/d' <br />13" <br />Test End Time (TF): 10:04 a.m. <br />10 :04 a.m. <br />10:04 a.m. <br />Final Reading (RF): 11 '/4" <br />11 '/a" <br />13" <br />Test Duration (TF - TI): 1 hr <br />l hr <br />1 hr <br />Change in Reading (RF - RO: 0 <br />0 <br />0 <br />Pass/Fail Threshold or 1/16" <br />Criteria: <br />1/16" <br />1/16" <br />Test Result: 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 />1 hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signa Date 06/22/2011 <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 />