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Data Charte"for Tank System Tightness Test MAY 2 0 1991 <br /> Ro-r Tate ENVIRONMENTAL HEAI7H <br /> i t—O/ O TANK TESTER <br /> PLEASE PRINT '7 <br /> 1. OWNER Property '® r/ O/L T14e'K�O � R.p,.. m T.Npnun. <br /> Nacos A0�a Addrua LGr✓� �!. '• <br /> Tank(Q ® TV S � C q.pwum rive Lbpnpna <br /> Name Addnu <br /> 2. OPERATOR Name Address bNonon. <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> Name Tide Company or Aflul.don O.te <br /> TEST AND WHEN <br /> Adduu Tsiepnn <br /> S. WHO IS PAYING ev' e— e!�,,Eg ` <br /> FOR THIS TEST7 Company.As...1 or Individual anon AamodaZia <br /> na lea. rele <br /> Billing Address Cay State 2Ip <br /> Attention of: 014.1 No. Other Inteucdon* <br /> Identify by Direction Capacity Bnmc1/Supplier Greek, Approx.Age Sud/Fiberguss <br /> 6. TANK(S) INVOLVED "T /006 d^^s /'/Oetsrmwy <br /> ,oc �p eso zeAlk r4w.9S <br /> As i DOSIr S <br /> Location Cover Fills vents Siphons Pumps <br /> 7. INSTALLATION fyl'd.d7� OF ��K <br /> DATA 9To.2� Z <br /> North Inside ddv*w.y, C...mle.Black Top. Sire,Thalia make,0100 Spcllon.Rameu. <br /> Rete of alatloA er.. Wor etc. tub...Remote FIll. Stu,M.nllolded Which onkt I Make it known <br /> 8. UNDERGROUND Is the water aver the ..it? <br /> WATER Depth to the Were,�table <br /> pp �N4W TN IIf� Yes No <br /> Tanks to b•filled(t•_ab� _0hr. yid/ Data Arranged by <br /> 9. FILL-UP Nam. Alaonone <br /> ARRANGEMENTS Extra product to"lop off'and run TSTT. NOW and who to provide? Consider NO Lead. <br /> r <br /> Terminal or other contact <br /> for notice Or Inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR, _ <br /> MECHANICS. <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials or other.to be advised when tasting is in progress or.omplaud.Visitors or observers present <br /> during teat etc. <br /> Tests were made on the above tank systema In accordance with teat Procedures prescribed for PPjro Tiffs <br /> 12. TEST RESULTS as detailed on attached lest charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Dat*Tested <br /> KGN/K —, o y-IF-q <br /> u e eros 4 <br /> Ar-,a--9 <br /> oz y- <br /> This Is to certify that these tank systems were tested on the date({)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION <br /> the National Fin Prot Ion Asoelalion Pamphlet 029. <br /> / 1 y9 Lawrence Tank Testing w ,� <br /> V 0v P.O. Box 407 er: amww <br /> BenN Saymo,No of .rmd tchn-42160 i.lane Downieville,California 95936 (916) 289-3109 <br /> Senear <br />