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Date Ct#rt for Tank SysternIfig ess Test � <br />►LEA51 PRINT <br />1. OWNER property [ Chevron U.S.A. Nark Nel on <br />Tanks) "T'Annabel Lane,Suite M,San ffamon `.SAA <br />w.me Adore" <br />(k 15 ) 5,6+0 19 3_v• <br />2. OPERATOR <br />.� <br />Name <br />a,eere.a <br />Regulations govern ng <br />under ground storage <br />of hazar of�i.a <br />3. REASON FOR <br />substances sucha ter 16 of chapter -3 of <br />b <br />title 23 of h <br />TEST <br />a ifornia Administration code. <br />(Explain Full,) <br />k WHO REQUESTED <br />TEST AND WHEN <br />M <br />�prr�a q{ ff�W t, <br />"7"eAnnabel Lane,Suite X100 San Ramon, CA ny§r!7Ao3 Date <br />Atloreu <br />Telephone <br />Chevron U.S.A. <br />Mark Ne n <br />415)S3A-5303 <br />5. WHuISPAYI�G <br />FOR THIS TEST? <br />`L"-` t'n*A"6:h1e l "" d rl e Suite <br />IM A7"'5%nh Ramon CA 9 4 5r-')Tehpnpne <br />sll,rnp At)pr.as B o b S t o l t z <br /><<., <br />suit Lp <br />Aiten,.o. or <br />Oroe• "c Other Inatructuom <br />Identify by Direction Ceo.cn. I <br />Brmd.'Suppt,e <br />Gods <br />Appro} Aqc <br />Steei/Flt»rptas. <br />�` <br />6. TANK(S) INVOLVED <br />I <br />i <br />Locat on <br />Cover <br />Fills <br />Vents <br />Siphons <br />pumps <br />7. INSTALLATION,' <br />I <br />DATA <br />North IndOt tlnoeway. <br />Rear of stauon, etc <br />I Concrete. slack Top <br />Earth• etc <br />Size, TOW.P make. Drop <br />tubes. Remote Fill% <br />Sae. manitoloeC <br />wtuch inks t <br />Sueeson. Ramou <br />Make it knowr <br />8. UNDERGROUNDIs <br />the wale, over the tank z <br />WATER <br />Depth to the Water table <br />yes <br />Tanks to be filled hr. <br />Date Harped by <br />Neme Telephone <br />9. FILL -UP <br />ARRANGEMENTS <br />Extra product to "top oft" and run TSTT. How and who to provide 1 Consider NO load. <br />Terminal or other contact <br />for notice or irpurry <br />Company <br />Name Telephony <br />t ' <br />10. CONTRACTOR, <br />any other Contractor <br />Involved <br />11. OTHER <br />fNFORMATION <br />OR REMARKS <br />Additional information on any items above Officials or others to be edvloed <br />during test etc <br />when tasting a in progress Of Completed Volidors or obaervan pecan. <br />Tests then made on Vw above flank systema in 0000rddnoo aakh fest prooadtsras proscribed for tru T& <br />12. TEST RESULTS N "tallied on isno d feel charts W"h restdte ae follows. <br />Tank Identification I Tight I Leakage Indicated I Dote Tested <br />13. CERTIFICATION <br />sole <br />This Is for wIII r that go" w flow" w" Igrbd .R ttn rows) hewn. lha bOuNd on -Mww slit N tfsk*osk" low <br />to kmuw of ►ve ►rwow Alaw"bon pow " IM r <br />' ` 1 <br />0.0- Box 2016 a <br />