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E <br />Dataart for Tank System Tig tness Test <br />4 <br />pP=Tite <br />PLEASE PRINT 0 o b # 2119 TANK TESTER <br />1. OWNER Property ❑ <br />City of Lodi, 221 West Pine Street, Lodi, Dick Wiech <br />Tank(s) El <br />rv(2 0 9) 3 3 4- 5 6 T I °hone <br />"� 1 t y of Lodi, 1331 S o Addrltsya m Lane, Lodi, C'�resenL"'(209)334-56 <br />Name Address Repraseotalive Telephone <br />2. OPERATOR <br />City of Lodi, 221 W. Pine Str. Call Box 3006, Lodi, Ca 95241 <br />Name Address Telephone <br />3. REASON FOR <br />Re ulationa governing underground storage of hazardous <br />TEST <br />substances, subchpater 16 of chapter 3 of title 23 of the <br />(Explain Fully) <br />C a I i f o r n i a Adminstration Code. <br />4. WHO REQUESTED <br />Dick Wiech, Maint. , Super., City of Lodi 8/06/87 <br />TEST AND WHEN <br />"' e, da Cpmpenv or Aff lief Deta <br />�L1 W. Pine Str., Cal Box 3006, Lodi, CA ��241-1910 <br />Address Telephone <br />5. WHO IS PAYING <br />City of Lodi, Dick Wiech, Maint., Super., (209)334-5634-690 <br />FOR THIS TEST? <br />cO'!!T- A_94 .c' darflWe" S t r . , Ca 1 ?"oB"dV'lT0 0 6 , Lodi , CA 9T562 41-1910 Telephone <br />alBing Address City state Zip <br />Attention of: Order No. Other Instructions <br />6. TANK(S) INVOLVED <br />Identify by Direction <br />Capacity <br />5,000 <br />Brand/Supplier <br />Grade <br />Unleaded <br />Approx. Age <br />Steel/ Fiberglass <br />------ <br />5,000 <br />Diesel <br />7. INSTALLATION <br />DATA <br />Location <br />" <br />,-�,da <br />North Insidaircinveway, <br />Rear of station, etc. <br />Cover <br />Concrete. Black Top, <br />Earth, etc. <br />Fills <br />L1 ' <br />Size, Titelill make, Drop <br />lubes. Remote Fills <br />Vents <br />Size, Manifolded <br />Siphones <br />- <br />Which tanks? <br />Pumps <br />Suction, Remote. <br />Make it known <br />8. UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table. �l % * Yes No <br />9. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by _ <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 Name Telephone ' <br />10. CONTRACTOR, <br />{.I <br />MECHANICS, <br />any other contractor <br />-- <br />volved <br />OTHER <br />11. <br />INFORMATION <br />OR REMARKS <br />_ <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present <br />during test etc. <br />,YYji <br />I ;A <br />h �.. <br />f(ij I <br />Tests were made on the above tank systems in accordance with teat procedures prescribed for petro?ftp <br />as detailed on attached test charts with results as follows:'^ <br />Tan Identification Tight r Leakage Indicated Date Tested <br />1.,�Ie 1 4 <br />HEALTH <br />NiV► <br />-- — <br />ER M11 /SERNTAL C,tS <br />13. 7—CERTIFICATION <br />L_-._. <br />D <br />Serial! 1011lo of Thermal <br />Senses <br />This is to ceAlty, that these tank systems were tested on the date(s) shown. Those Indicated as "Tight" most t cri7iiiia established by <br />the National Fire Protection Asoclation Pamphlet 329. <br />- V-, ��/4 _� _NORTH CAL CONSTRt ICTInN <br />UT utp <br />in C nscl - gnalu <br />Post iiic� i�ox �R# Company. Com=, ..-- <br />Technicians .CA 95201Address <br />