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Data Art for Tank System Tigh Ass Test <br /> PLEASE PRINT PEMC. <br /> 1. OWNER Property ❑ RMC LONESTAR INDUSTRIES, PO BOX 5252, PLEASANTON, CA 94566 <br /> ❑ Name Address Representative Telephone <br /> k <br /> Tans) 835-1454 <br /> Name Address Representative Telephone <br /> 2. OPERATOR RMC LONESTAR INDUSTRIES SOUTH TRACY BLVD. , PLEASANTON, CA 94566 <br /> Name Address Telephone <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBSTANCES <br /> TEST SU& IAPTER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE CODE <br /> (Explain Fully) <br /> 4. WHO REQUESTED OWNER <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING OWNER <br /> FOR THIS TEST? Company.Agency or Individual Person Authorizing Title Telephone <br /> Billing Address City State zip <br /> Attention of. Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED 11000 UNLEADED <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION WEST OF EARTH 4 tt OVERFIAW 11, SUCTION <br /> DATA SCALE HOUSE BENNETT <br /> North inside driveway. Concrete.Black Top. Size.Tifefill make.Drop Suction,Remote. <br /> Rear of station,etc. Earth.etc. tubes.Remote Fills Size,Manifolded Which tanks? Make if known <br /> 8. UNDERGROUND is the water over the tank? <br /> WATER Depth to the Water table ❑ Yes ❑ No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Telephone , <br /> ARRANGEMENTS 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 /> MECHANICS. _ <br /> any other contractor <br /> involved <br /> 11. OTHER — <br /> INFORMATION <br /> OR REMARKS SAN JOAQUIN COUN'T'Y <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 /> Tests were made on the shove tank systems in accordance with East procedures prescribed for <br /> 12. TEST RESULTS as detailed on attached test charts with alts 3�7811owfe "� <br /> Tank Identificat on Tight e_akage In is I Date Tested <br /> LKLMED TI <br /> I <br /> This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight"meet the cfiteria lostabNshed by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> 02-17-89 BILL CAMPBELL PETRO-CHECK, INC. <br /> Dau Testing Contractor or CompanB :, Signature 85838 <br /> 1854 414811816 271 Opportunity St., Ste. "'C, Sacrament0, CR <br /> Senal No.of Thermal Technicians Address <br /> Sensor <br />