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5. WHO IS PAYING <br />FOR THIS TEST? <br />or Individual Person Authollpine Title Telephone <br />-- --- --suds— <br />Identify <br />- - <br />City erne _.., <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />3 6 ' 419 <br />Data Ch0. <br />for Tank System <br />petro Tito <br />TightnA Test <br />TANK(S) INVOLVED <br />PLEASE POINT <br />10 000 <br />TANK TESTER <br />Die <br />1. OWNER Ptoperdy <br />k Poultry <br />Farm 320 S. <br />Stockton, Ripon Cal 95366 _ <br />en <br />Tk(s) ❑ <br />Name <br />Wt <br />Address <br />Addresc <br />Red rnemalire <br />ote <br />Xesen—Nuve <br />Telephone <br />/,Yarm\ r <br />F�'� 9 i--39 aIs hi' e <br />2. OPERATOR <br />Name Address <br />Telephone <br />3. REASON FOR <br />rnI i forni a gt;3tp <br />T,aw <br />TEST <br />(Explain Fully) <br />Locatiq-n tfJ 0� <br />u1ARkJt � Ma <br />��IAtV aldl <br />y u <br />North inside driveway. <br />flour of stabpn, mc. <br />----'"--'--- <br />-- <br />— <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Walt Den Dulk <br />Name <br />—_-@10:00 <br />Tine <br />_ <br />Company or Affiliation <br />2-2-82 <br />Date <br />Is the water over the tank? <br />Addrns <br />WATER <br />Teleonone <br />5. WHO IS PAYING <br />FOR THIS TEST? <br />or Individual Person Authollpine Title Telephone <br />-- --- --suds— <br />Identify <br />- - <br />City erne _.., <br />I <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />6. <br />TANK(S) INVOLVED <br />U k <br />10 000 <br />Die <br />Steel <br />Unk <br />6 000 <br />Die <br />_ <br />Steel <br />7. <br />INSTALLATION <br />DATA <br />Locatiq-n tfJ 0� <br />u1ARkJt � Ma <br />��IAtV aldl <br />y u <br />North inside driveway. <br />flour of stabpn, mc. <br />Cove L <br />q <br />Concrete, Black Top. <br />Earth, are <br />Fills )Ogp <br />f f l Ua fir) <br />33,1. l• <br />Site, Tlreflll make, Drop <br />tubes, Remote Fills <br />Vents !t �/p, COD <br />. %t 1 t00p <br />.� <br />Size. Menitobed <br />Siphons <br />7 <br />11 <br />�^vp1T <br />Which Oaks 7 <br />Pumps <br />///I�NRCIJ !�S <br />Suction, Remote. <br />Make it known <br />B. <br />UNDERGROUND <br />,7 I <br />Is the water over the tank? <br />WATER <br />Depth to the Water table _— !!_ -.-_ <br />El Yes t� No <br />9. <br />FILL -UP <br />Tanks to be filled hr. Date Arranged by <br />Name Teleonone <br />ARRANGEMENTS <br />Extra product to "top off' and run TSTT. How and who to provide? <br />Consider NO Lead, <br />Terminal or other contact <br />for notice or inquiry <br />_ <br />Company <br />_— <br />Name Teieonone <br />10. <br />CONTRACTOR, <br />-- <br />--— <br />MECHANICS, <br />any other coduacon <br />involved <br />-- -- <br />----'— - -- <br />11. <br />OTHER <br />----- — ----- ------ <br />INFORMATION <br />OR REMARKS <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present <br />during test etc. <br />Tests were made on the above tank systems in accordance with test procedures prescribed for PpjrO T11P <br />12. <br />TEST RESULTS <br />as detailed on attached test charts with results as follows: <br />"a <br />Tank Identification Tight Leakage Indicated <br />- — - <br />Data Tested <br />Passed <br />---- <br />- <br />Failed <br />— --- <br />Cert. / <br />------ <br />- ------ <br />Paid <br />- - <br />q�-1 <br />Churg <br />FFR1C` <br />Inv. <br />County <br />ENVIROMEJTAL HEALTH <br />F CDAAIT/c CDXJIr1C0 <br />I <br />