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° SWRCB, January 2002 E C —'F an sEr B ? This form is intended for use by contractors performing periodic testing of UST secondary containment Bek' _ ;LA T appropriate pages of this form to report results for all components tested. The completed form, written testOK, ` IP printouts from tests (f applicable), should be provided to the facility owner/operator for submittal to the local regulatory agen 1. FACILITY INFORMATION Facility Name: HAMMER LANE OIL Date of Testing: 06/25/10 Facility Address: 3304 W. Hammer Lane , Stockton CA Facility Contact: Mike Gurm I Phone: 209-992-1415 Date Local Agency Was Notified of Testing: 06/25/10 Name of Local Agency Inspector (ifpresent during testing): Garrett Backus 2. TESTING CONTRACTOR INFORMATION Company Name: Reliable Petroleum Services Inc. Technician Conducting Test: Guadalupe Sanchez Credentials: X CSLB Licensed Contractor ❑ SWRCB Licensed Tank Tester License Type: "A" License Number: 883706 mssn Manufacturer Training Manufacturer Component(s)) Date Trainin Ex ires 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 1 ❑ ❑ ❑ ❑ 1 ❑ I ❑ ❑ If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING To the best of my knowledge, the facts stated in this document are accurate and in full compliance with legal requirements Technician's Signature: Date:06/25/1.0