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P.O. 110, 30�107 <br /> • ( ��TING & CON-rIl j-i-ION CO. <br /> S10CKTIIN, CA 95213 <br /> (7.09) 931- 1 OZO 1-ICENSEU <br /> "AX (209) 465-30or 11ISI1REp <br /> O * ** * W'rEST REPO17'I, <br /> urNr:R Orru�pt LICENSE '�,�92-1248 <br /> ADDRF,SS:-04co 1-6 LEONAPo E. CRISP <br /> 1 - CITY: _ _ l � _ <br /> OWNFR OF TANKS: 7,o, � <br /> ,P Yl f G_- olam(/U <br /> ADDRESS:._ - <br /> CiTY: <br /> OPERATOR AT LOCATION:-- - <br /> --_A(YI.C_Gl _� <br /> ADDRFSS:_ " <br /> _ <br /> r - - - <br /> COUNTY.' <br /> OUNTY t�.6� 1 I,ti���U( l 1 T'A NK++:,. - 71P: <br /> _ - AGE: , JCX�. <br /> GAi,LONS: �ir _ <br /> MET'AI,(� FIBFRGi,ASS( ) SiNGLF WAI.i. UOUBi,F. WAI,LFU( <br /> I-,I) - ) <br /> DIESEL( ) UNLFADF ) PREMiUM 11'1,. ( ) <br /> SUCTION( ) S(JBMERSIBI.F0 OVFRSPi1,1. CONTAiNFR-'YF.S( ) NO¢,,) <br /> SHEAR VAI,VE'*YF.S(/) NO( ) IN LiNF LEAK DFTFC'TOR•'YF,S <br /> VAPOR RECOVFRY SYSTE •' ) NO <br /> M YES(X) NO( ) iF YFS, PHASR iX(AIiASF Ii( ) <br /> TANK FILL DAT'F:-_ 'q T'iPoTF: /9 00 <br /> TANK TEST DATF,:S- '"- C START'J.Q / T <br /> LENGTH OF TF,ST:4_/ - F,ND:�s115 __ <br /> TANK BOTTOM TO GRADE.....__I_.jJ_ <br /> TANK TOP TO GRADE............ y3 TEST' LEVEL TO TANK BO'TT'OM.. ..- r� <br /> - GROUND WATER ABOVE. TANK../'�' <br /> DIAMETER.,.:.............. - -� PSI............ <br /> TEST LEVF,i, ABOVE GROUND.--_U?-3 ." .. r_d�(2_ <br /> _ NFT' TEST PRF.SSIJRF...................... __ ( I <br /> WATER 1N TANK.................... __-�--_--•� <br /> DEPTH FOR TAKING SAMPLr ---K APi SPECIFIC GRAVITY................. 5 J <br /> TFMPFRATURF PROBE, DF,PTiL... - _ i'F,MPFRAT[JRF..................... ...........f r <br /> APi SPF,CiFiC GRAViTYo 60' F...... t Jr - <br /> COFFFICIF.N'I' OF F:XP..................._r�r? )-;�i76 <br /> LEAK RATE PFR/HR:. /.. <br /> CFRTiFIFD T'1GHT: YFS(yJ. ND( ) <br /> PRODUCT iANF TEST': SUCTiONV) PRESSURE( ) <br /> LF,AK RATF, PFR/i1R: / v — <br /> CF,RTIFIFI) TiGHT: YF. i]O( ) <br /> SiGNAT'URE OF TFSTFR:" a <br /> --- <br />