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A; <br />PLEASE PRINT <br />Chat pion <br />Precision Tank Testing <br />License No. 73848 <br />DATA CHART FOR TANK SYSTEM TIGHTNESS TEST <br />1. OWNER Property ❑ <br />Tank(sl ❑ <br />Name Address Zip Representative Telephone <br />Name Address Zip Representative Telephone <br />2. OPERATOR <br />7-11 # 19976 1399 NORTH MAIN MANTECA CALIF. <br />Name Address Zip Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBSTANCI <br />SUBCHAPTER 16 OF CHAPTER 3 TITLE 23 OF CALIFORNIA ADMINISTRATI' <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Name Title Company Or Affiliation Date <br />Address Zip Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identity by Direction Capacity Brand/Supplier Grade Approx. Age Steel/Fiberglass <br />NORTH SOUTH 10,000 BENETO PREMIUM <br />NORTH SOUTH 10,000 TANK MID GRADE STEEL <br />NORTH SOUTH 10,000 LINES UNLEADED STEEL <br />6. INSTALLATION <br />DATA <br />Location Cover Fills Vents Siphones Pumps <br />EAST CONCRETE 411 211 TOKHEIM <br />OF STORE SUCTION <br />North inside driveway, Concrete. Black Top. Size. Titefill make, Drop Suction. Remote. <br />Rear of station, etc. Earth, etc tubes, Remote Fills Size. Manifolded which tanks' Make if known <br />7. UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the water table from grade BELOWTANK / WELL POINT ❑Yes CNo <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled 070 Ohr. 5 / 2 7 / 9 2 Date Arranged by <br />Name Telephone <br />Extra product to 'lop off" and run tank tester. How and who to provide? Consider NO Lead. <br />TESTING CO <br />- <br />Terminal or other contact BENETO TANK LINES wRsT SArRAMFNTn CALTF. <br />for notice or inquiry <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />SELF LEVELING STANDPIPE AND -JIT -S-2,_000 <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present during test, etc. <br />11. TEST METHOD+❑ <br />PETRO TITS # 2 <br />❑ PETRO COMP <br />❑ OUICK CHECK 2000 <br />11a. TEST RESULTS <br />Tests were made on the above tank systems In accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight Net Volume Change Per Hour Date Tested <br />REMIUM YES —.25 5/27/92 <br />MID GRADE YES —.016 <br />YES —.020 <br />12. SENSOR <br />CERTIFICATION <br />1/23/92 <br />Technicians <br />tW.CAMPBELL CHAMPION'S PRECISON TANK TESTING WU%�— <br />Data <br />418 <br />Tasting Contractor or Company. By: Signature <br />certifications 92/1324 P.O. BOX. 13059 SACRAMENTO CALIF 95831 <br />Serial No. of Thermal <br />Z 916-927-1557 1-800-660-9443 CALIF. <br />.SACRAMEN_TO 1-800-949-9443 NEVADA <br />ri r ► <br />ES <br />ifE <br />