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Data C' In for Tank System Tight- z Test <br /> clu"ICIN's rltRCl CN 7= lZSTM <br /> 1451 Oakhurst Way, Sacramento, CA 95822 a <br /> PLEASE PRINT (916) 927-8155 • (800) 344839 <br /> 1. OWNER P.*wv ❑ tea„ . _ r.hnww <br /> Tank(w) El Me. 209-823-11-i5L'R n Lewis <br /> �� TY.pkon. <br /> N,nM Adder <br /> Same J <br /> 2. OPERATOR <br /> N,wr <br /> ;. REASON FORCAT.TFORNCES <br /> TEST SUBCHAPTER 16 of CHAPTER 3 of TITLE <br /> (E.Phi.FURY' ADMINISTRATIVE CODE <br /> 4. WHO REQUESTED OWNERone <br /> Nwww Tly Cornoaffr p ANaaOWr <br /> TEST AND WHEN , , , <br /> Adwwn <br /> 5. WHO IS PAYINGPefwM AOmpidq ries rw.rten.rae <br /> FOR THIS TEST? retw.aYM <br /> own Address cdr saw <br /> Anenlinn of O/GN NO. OOwf IMnYC1ipK <br /> 1° [ Davvmn C.pPdq e""/SYPpir G,aftr MVP•.AW SUM/FOWyltfb <br /> 6. TANK(S) INVOLVED ` <br /> Fit Venda $rptafaa Panye <br /> 7. INSTALLATIONh!aT � <br /> DATA <br /> / SYce,on.ewiew. <br /> Norm Malde dd.wer. [oI1CMe.e,AR,.TOP. sin.TIIMa W.ta MOO ,yet,Ann"? Make d k. <br /> RW M NAM.eff.. 4M.Mc. trrCi RMaw PAR, Si[a Wrilof0.0 <br /> IS dw wab,Ore,f VIA tank? ' <br /> 8. UNDERGROUND 0 y„ No <br /> WATER Dpth b the W~able <br /> Tariks lobe filled b. DAN, A,n,fled b/ <br /> 9. FILL-UP Efe„ad„,,to`too on-and run TSTT. "ow Mw web b I►o."? Gorman NO Lead. <br /> ARRANGEMENTS <br /> Tenninel p 01M,COnUCt <br /> NN nMKe p MCYW— CMww Nwn. TM.MaM <br /> 10. CONTRACTOR ----- <br /> MECHAMCS. <br /> any WRe,convacta, <br /> Inrpwd <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additanal inlpmatron on any iUma aeo.e.OHicah p pHwrw b be Wvi.ed when bating h M poq,eas p eornPle<ed.Vrarlps p oEM.ps MeenE <br /> dYnrq Uw,etc. <br /> Tests were,made on the,sivOtn tank sYsafae M acca denco with We p,oudfNaa Weecnwd a, > <br /> 12. TEST RESULTS AS de,Uiad on sDaPMd I"`hurts e,rnlf H flx AS tpivows: <br /> Tank IdwnYl wn TqM Loakwlw Ind"t*d One Tswd <br /> r� r'- <br /> Tads a b ce,tM ew tale,taftiv sVon rove,IsO W M tae dsst(s)sM Trow I,tdlcased�"Tt1Pa"n,ssl Iles fallsrY ssEtlsl�O wr <br /> 1e,. CERTIFICATION da N.naall Five,P,oac w AWIddlbsn Pssfp"3214 <br /> g_I;—RQ William Campbell Champion' sPrecision Tank Tasting <br /> p,w TneAe opt nwr or oaWnr. r MbN <br /> 414811816 1451 Oakhursrt Way , Sacramento , Ca. 9581,6 <br /> T.......... Add,.f. <br />