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SWRCB, January 2006 <br />Spill Bucket Testing Report Form <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 ownerloperatorfor submittal to the local regulatory agency. <br />1. FACILITY INFORMATION <br />Facility Name: Hammer Lane Oil Inc. Date of Testing: 06-25-10 <br />Facility Address: 3304 W. Hammer Lane Stockton CA <br />Facility Contact: Mike Gurm Phone: 209-992-1415 <br />Date Local Agency Was Notified of Testing: 06/15/10 <br />Name of Local Agency Inspector (ifpresent during testing): Garrett Backus <br />Test Method Used: X Hydrostatic 0 Vacuum 0 Other <br />Test Equipment Used: Standard Tape Measure <br />Equipment Resolution: <br />_,77,77 7 7 <br />Identify Spill Bucket (By Tank <br />Number, Stored Product, etc. <br />T3: Diesel <br />FILL <br />Bucket Installation Type: <br />X Direct Bury <br />0 Contained in SL=p <br />0 Direct Bury <br />0 Contained in SLmp <br />11 Direct Bury <br />0 Contained in Sum p <br />11 Direct Bury <br />0 Contained in Sump <br />Bucket Diameter: <br />12" <br />Bucket Depth: <br />137/811 <br />Wait time between applying <br />vacuum/water and start of test: <br />)min <br />Test Start Time (Ti): <br />1:20p.m. <br />Initial Reading (RI): <br />13" <br />Test End Time (TF): <br />2:20p.m. <br />Final Reading (RF): <br />13" <br />Test Duration (TF — TI): <br />1hr <br />I Change in Reading (RF - Rj): <br />0 <br />Pass/Fail Threshold or <br />Criteria: <br />1/16" <br />Test Result. <br />X Pass 0 Fail <br />0 Pass 0 Fail <br />0 Pass 0 Fail <br />0 Pass 0 Fail <br />t.omments — (include information on repairs made prior to testing, and recommended follow-up for failed tests) <br />Replaced spill bucket on Diesel (Fill) <br />CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING <br />I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements. <br />Technician's Signature: <br />Date:06-25-10 <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 />