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Data ChIk for Tank System Tightness Te <br /> CEIVE <br /> CMLWPIOAR'S PMISION TW TESTING MAY 2 1 1990 <br /> PLEASE PRINT ENVIRONMENTAL HEALTH <br /> I. OWNER Property ❑ Southland Corporation 4558 Roseville -Rk . North Highlands Ca 95660 <br /> Nam. <br /> Tank(t) El Greg CratRaw uanuti.. Abonom <br /> Name <br /> Aaeress Raoieaenuuvs T.Lonon. <br /> 2. OPERATOR p A <br /> Nam. Aaar.b <br /> TeleDnen. <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE <br /> TEST SUBCHAPTER 16 OF CHAPTER 3 OF TITLE 23 OF IhE CALIFORNIA ADMINISTRATIVE COD <br /> (Explain Fully) <br /> 4. WHO REOUESTED OWNER <br /> TEST AND WHEN Nam' Tnb <br /> Company or ANnxuoe Dab <br /> Adds., <br /> T.bpnon. <br /> 5. WHO IS PAYING OWNER <br /> FOR THIS TEST? Company.Agency or Imw Oeu Person Amnominp <br /> Ties T.I.pnow <br /> aininp Addm' Cnr <br /> Sub zip <br /> Aeantion ol: Ordsr Na. Otho Inapucuons <br /> Identify by Direction Capacity Brand/Supplxr Grade <br /> 6. TANK(S) INVOLVED. .111 S` r a( I Approa.Age Steel/F barplass <br /> v <br /> 1 L v ,,�, <br /> ,T ; <br /> location Cover Fills Vents <br /> (�Ey�k� Sipnonas Pumps <br /> 7. INSTALLATION 1e aGea <br /> DATA oQo r <br /> 5"ft",tC. � lq 6. <br /> (( "�f. k �s T r <br /> Nonn imi4*driveway. ConCfta.Black Too, Sita.Tilehll mate.Drop <br /> Rear of s en.f..1. Eanh.air. IUEes.R.mom Fill, S¢..MandobedSuron.Remol.. <br /> 6. UNDERGROUND vni`n a"kS.01...Make it an.. <br /> WATERD<pih to the Water fable Is the water over the tank if <br /> El ❑ <br /> Yes No <br /> Date Arranged b <br /> 9. FILL-UP Tanks to be filled—b'' 9 r— <br /> ARRANGEMENTS Extra Product to"top off'and run TSTT. How and who to provide? Consider NO Lead Name rexpnon. <br /> Terminal Or other Contact NOT APPLICABLE r <br /> for nonce or inquiry, <br /> CompanT Name Teiepnpne <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved IS <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Addmonal inlormatwn on any items above.Dflival$or others to be advrsed when testing b m progress or complebd.Vbdprs or observers present <br /> tlunnq test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for }FO TIP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: - <br /> Tank Identification Tight Leakage indicated I ' <br /> Oale Tested <br /> O <br /> if. A J �i- ` - Go <br /> I <br /> i ( <br /> I <br /> This is Io certify that these tank systems were tested on the date(&)shown.Thou uted as"Tight"meet the criteria established by <br /> 13. CERTIFICATION <br /> me is <br /> Fire Protection Asocistion Pamphlel 329. it <br /> Dau R Qn �/1Wt��9� iwt CHAMPION'S PRECISION TANK TESTING 1 <br /> recon contiaao.or tam <br /> Bit Ckf <br /> G 822 <br /> Z < ►-3� A/ 1451 OAKHURSYe N}AY, sACRA r1 I <br /> $wed Flo of TM.mN T.Cmm�ans I <br /> AUObb <br />