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HORNER_EZY_CHEM::_TANk__CERTIFICATION_REPORT <br /> --------------------------------------------------------------- <br /> CHAMPION PRECISION TANK TESTING (916) 927-1557 (Soo) 66o-9443 <br /> License #73848 <br /> Owners___ � r_�_F'rope�y --------------Tan k: (s) ---- <br /> Company 1_ V L1�/ _1,J1'T' �---- Phone_ (aD�) <br /> Address: oKt_ul - _ ____________ <br /> CitY : ------------ State! --M <br /> ----- Z i p ; � 2a----- <br /> ---------------------------------------------------------------- <br /> Name of Location <br /> Company= sS�f3cP _ (L+QP�_ �/��[lPhone_ (Ua)SJ 9' - 670.3 <br /> --------------- <br /> Address:_ --------------------- <br /> ---------------------- <br /> ---------- <br /> Ci ty 1 _�SP/lt_Q/.I----------- State :---4----- zip : _gs-3 �----- <br /> ----------------------------------------------------------------- <br /> Notice_to_owner (s_)_ A copy of this test result has been filled <br /> with Proper Regulatory Agency. To:______________________________ <br /> Reason_For_Test________________________________ <br /> ----------------- <br /> Notice_ It is the responsibility of the owner to contact the Env. <br /> health Dept. of any failure on tank (s) within (24:• hours. <br /> ----------------------------------------------------------------- <br /> Who Requested & When? <br /> -------------------------------------------- <br /> Date : <br /> ---------------------------------------------- -------------- <br /> ----------------------------------------------------------------- <br /> [3Tank Only O Product Line O Vent Line O Vapor Line O All of these <br /> - - - - - - - - - - - - - - - - <br /> Identify : Capacity : brand : Grade Age : Steel Fiberglass <br /> by ID# Supplier <br /> ---1----1--Lob D--- ----- I ---- ------------ <br /> ---�`---1 -FOOD--1 ---------1 L 1-------------- ------------ <br /> -------------- ------------ <br /> --------1 ---------1---------1 -------- -------------- ------------ <br /> -------------- ------------ <br /> -------------- ------------ <br /> Tanks <br /> ------------------------- 1------------ <br /> --------------1------------ <br /> Tanks to be filled______ For :__-_----__Date :------------ -------- <br /> Distributor : ------------------ Extra to topp-off : <br /> ------------ <br /> Commentsl -------------------------------------------------------- <br /> _ Representives or owners will be <br /> notified when the test is completed and one offical must be <br /> present during the testing. All tests made on the tank (s) systems <br /> are valid with the Horner Ezy-Chek leak detection procedures. <br /> This certification shows the criteria established by the National <br /> Fire Association (Phamplet 3291 . <br /> ----------------------------------------------------------------- <br /> Test Results Tan ks,Product Lines, Vent, Vapor Lines Inc. Yes O No <br /> Tank Tight Tight Leak/Per Leak/Per D to <br /> ID# Tank Lines Ind.Tank Detected Line Tested <br /> --------------- - ---- <br /> 4 - --- <br /> --�--- --Y -N ❑ Y10 <br /> N O „y �1---I --- ------'- - <br /> -- -- I Y g No YD N O - ' 10 --- =------ <br /> YO <br /> -----YO NO YO NO I---------- --------------- - <br /> ------1 Y O N 0 1 YO NO 1---------- ---------------:---------- <br /> ------1 YO NO 1 YO NO 1----------1---------------1---------- <br />