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PLEASE PF11N1 <br />Data C rt for Tank System Tightness Test <br />petro Tits <br />Job fl 2 1 1 8 TANK TESTER <br />1. <br />OWNER property J <br />_City of Lodi, 22.1 _W. Pine Street, Lodi, <br />Dick Wiech <br />Tank(s) n <br />NC"i t y of Lodi, 1331 S o "dd'W'dm Lane, Lodi, e7kie5Bniati\ <br />2 0 9) 3 3 4- 5 6 Y phpn <br />Name Address Representative <br />Telephone <br />2. <br />OPERATOR <br />City of Lodi, 2.21 W. Pine Str. , Call Box <br />3006, Lodi, <br />Name Address <br />Telephone <br />3. <br />REASON FOR <br />Regulations governing underground storage <br />of hazardous <br />TEST <br />substance, subchapter 16 of chapter 3 of <br />title 23 of the <br />(Explain Fully) <br />California Adminstration Code. <br />4. <br />WHO REQUESTED <br />Dick Wiech, Maint. Super., City of Lodi <br />8/06/87 <br />TEST AND WHEN <br />Nam tie or h o Datc <br />2h W. Pine Str_. , Cal Box 3006, Lodi,Comp CA SMI -1910 <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />City of Lodi, Dick Wiech, Mai nt. Super., <br />(209 334-5634-690 <br />FOR THIS TEST? <br />c2"YT• AVncy of lrld'616a' S t r . , C a 1 ie"'B o"Si070 06 ,_L o d i , C a <br />97512 41-1910 Telephone — <br />Biiling A301"s City <br />State Zip <br />Attention of: Oraer No Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />f ' <br />Capacity <br />500 <br />Brand!Supplier <br />GradeApprox. <br />Waste oil <br />Age <br />Steel( Fiberglass <br />-- <br />7. <br />INSTALLATION <br />DATAr-e <br />Location <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />1; - <br />Concrete, Black Top. <br />Earth, etc. <br />Fills <br />Size, Titelill make, Drop <br />tubes. Remote Fills <br />Vents <br />tr <br />Size, Manifolded <br />Siphones <br />Which tanks? <br />Pumps <br />Suction, Remote. <br />Make it knowvn <br />8. <br />UNDERGROUND <br />WATER <br />Depth to the Water table. <br />Is the water over the tank? <br />Yes No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled !�?`-' hr. L' Date Arranged by i U ! C- <br />Name Telephone <br />Extra product to "top off" and run TSTT. How and who to provide? Consider NO Lead. <br />Terminal or other contact <br />for notice or inquiry <br />Company <br />Name Telephone <br />10. <br />CONTRACTOR, <br />t ' <br />MECHANICS, <br />any other contractor <br />_ <br />— <br />involved <br />11. <br />OTHER <br />' <br />INFORMATION <br />OR REMARKS <br />Z �• <br />a I <br />TEST RESUL <br />AUG 1 ��--- <br />'IROMENTAL HEALTH <br />Additional information on any items above. Officials or others to be advised when testing is to progress or completed. Visitors or observers present <br />during test etc <br />Tests were made on the above tank systems In accordance with test procedures prescribed for PPiEO TItP <br />as detailed on attached test charts with results as follows: �- — <br />Tank Identification Tight Leakage Indicated Date Tested <br />-- i--- <br />— <br />---- - <br />--"- "--- <br />— -- --- <br />:ERMIT/SERVICES <br />--- ---- - -- <br />---- — <br />--- <br />---- --- <br />---. <br />13. CERTIFICATION <br />Date <br />4 <br />Sana' N,. d lhennn <br />Se r. snr <br />This Is to certify that these tank systems were tested on the date(s) shown. Those Indicated as "Tight" met the criteria established by <br />the National Fire Protection Asociation Pamphlet 329. <br />NOR I <br />_ i_ -- --- -- - -- LlTlt(�v`C�r{II3.4Atiur�.�-- <br />. i t <br />_.-. le. r.ru ie•�_. _.. -.--__�li)i ltt—_-_ _ -r._.Address _�f_ <br />oil, <br />C A 95201 <br />