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uata tonan for IaM bystem i igntness nest <br /> pe <br /> ±0 <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER P,owny E] Ahca P.0_ Bo 5811 San Mateo, Cati.6. 94402 Ron Mitu 1-800-421-7457 <br /> Name Addreft Repr*fenutiw <br /> Tank(s) <br /> Name Addless Rpr*s*ntatiw Telephone <br /> 2. OPERATOR ARCO #6080, 85 L. Louise Ave./Interstate 5, Lathrope, UA <br /> AddrMf - — —_--- Telphone <br /> 3. REASON FOR To check 4ok ti_ghtnus <br /> TEST - --- <br /> (Explain Fully) <br /> 4. WHO REQUESTED Ron Mita Anco <br /> TEST AND WHEN No"P,V, Box 5811 San Mateo;""Ca.Ei_SoAnia 9_4402 cDmp.nyerAnlltatlon bame. <br /> Address, T*lephone <br /> 5. WHO IS PAYING Akco Ron Mita game <br /> FOR THIS TEST? f .V"y'f1 ty 51l 1 us' San Mateo, 't (" yMa 94402 T"" Telephone <br /> @wins Address city state zip <br /> Attention of: Ober No. Other Instructions <br /> Identify by Direction capacity is1111lr flKqAA0 APPmx•Ape Steel/Fiberglass <br /> 6. TANK(S) INVOLVED &_XLU u L- KS r <br /> ltdc?1"1Z <br /> o UA,LC- 0-b <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION <br /> DATA �. �' <br /> NonA Inalde ddvewey, cit.Black Top. Site,Thefx11 make.Oroo Suction,Remote, <br /> Rost of station,oft. Earth.etc. tubes.Remote Fills Site.Msnffolded Which tanks 7 Make If known <br /> 8. UNDERGROUND Is the water over the tank <br /> WATER Depth to the water table L 4 <br /> yea Q� <br /> 9. FILL-UP Tanks to be filled A.00 4 h. /'A--0 jr Date Arranged by oN I I)/'L5 !-goo-'-o <br /> Name Telephone <br /> ARRANGEMENTS Extra product to"top oft**and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquily <br /> Company Ham* T11*phone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER ) 'fti ger, r�GKG,4i5, <br /> INFORMATION u 'G S'i6 6cic c7r ' r mit L c l f,�ivv = <br /> OR REMARKS <br /> Additional information on any items above.Officials OI others <br /> during test etc. to be advised when testing is in progress or completed.Visitors or observers present <br /> Tests were mads on the above Uw*systems In accordance with test procedures prescribed for ortro <br /> 12. TEST RESULTS as detalted on attached test P�► a with results as follows: `�`rliba <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> or <br /> 13. CERTIFICATION �is Natt�Protthat ection A�a�P�a��on��«s)shown'Tho a Indicated as�•Tbht~ft».t the criteria established by <br /> mphlet 329. <br /> Date LC I <br /> „(��'�G� •/1. ./` <br /> 414811897 P Tai np Contra�tDr Dr Company. Sionatun <br /> . 0. Box 1220, Tulare CA 93 Z,S ` <br /> SerW No.Th Th.rm.1 -.•-�nnkups Addre.c - <br />