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L.B-M-Ea CORPORATION <br /> setroleum Testing and Monitoring* PfC4 IfE <br /> Data Chart for Tank System Tightness Test ��T <br /> 1. OWNER Property <br /> weme A pros �M Rrpr en IW Tetevnone <br /> Tank(a) ( _ off/ urr©") �. <br /> Name Address - Represenishve _ _ - 701.01,0.0 <br /> 2. OPERATOR <br /> warn. VC dyl <br /> ^f Addlns Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) jr <br /> 4. WHO REQUESTED � ' <br /> TEST AND WHEN weme Thea Company or AlfuDais <br /> .1. <br /> Address <br /> Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company,Agency or lndividvol Person AuthoAzing Title Telephone <br /> aralnm Address Clly fiats Zip <br /> I ' <br /> Atrenrlon of Order no. Other Instructions <br /> ldentity by Direction Capacity Brand/Supplier Grad Approx.Age Steel/Fibaegfass <br /> S. TANK(S) INVOLVED t <br /> Local Cover Fills Yenta Siphons& Pymoy <br /> 1. INSTALLATION �/o�7W <br /> DATA p��IzA (f t/G F / z!r �/ f31or <br /> North Inslde driveway. Controls,Slack Too. Size,Th.fill make.Drop - Suctbn,Remota• <br /> w.er e!uatlnn•arc [tui.,arc. labra,wrrwala fall tae,Menhot ell Which Is nts l Make 11 known <br /> S. UNDERGROUND Is the water over the tankr <br /> WATER Depth to the Waley table �" /.9�/y ❑ Yrs 'No <br /> 9. FILL-UP - Tanks to be filled hr. Data Arrariged by <br /> S Name Telephony <br /> ARRANGEMENTS Extra product to-top oft"and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name <br /> Telephony <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional infortnalion on any Items above.Officials or others to be advised when testing is In progress or completed.Visitors or o;..arvars pruenl <br /> during lest Vic. <br /> Taste were made on the above tank Systeme to accordance with toot procedures prescribed for pp f0 Tt�' <br /> 12. TEST RESULTS as detailed on attached tut charts with results as t000ws; Lr <br /> Tank 2donlificaticift Tight Leakage Indicated Dale Tested <br /> �S . 933 07 <br /> This is 10 oertify that these tank systems wen tested on the date{e)shown.Thome(ndluted as"Tight'meet this crildris astsbllshed <br /> the National Fire Protection Asoclation Pamphlet 329. t'Y <br /> 13. CERTIFICATION <br /> / . <br /> case I-RM.E.CORPORATION <br /> 7 3814 Auburn Blvd.,Suite$2 ■r: sr9nawre <br /> S«..l he.a The+mal Tathni�ians •SacraTnent0,CA 95821 <br />