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4 <br /> Data C& for Tank System Tightr&s Test <br /> 0 0 <br /> PLEASE PRINT prM&CM WC. <br /> 1. OWNER Property ❑ RMC LONESTAR PO BOX 5252, PLEASANTON, CA 94566 <br /> ❑ Name Address Representative Telephone <br /> Tank(s) PILL KELTON (209) 835-1454 <br /> Name Address Re r Telephone <br /> 2. OPERATOR RMC LONESTAR SOUTH TRACY BLVD CY, CA 94566 <br /> Name Address ---- Telephone <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBSTANCES <br /> TEST SUBCHAPTER 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 Compsnv of 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 1.000 UNLEADED <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION WEST OF EARTH 411 OVERFLOW 111 SUCTION <br /> DATA SCALE HOUSE BENNETT <br /> North inside driveway. Concrete.Black Top. Size.Titsfill 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. Data Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off'and run TSTT. Now 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 COUNTY <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 above tank systems in accordance with test procedures prescribed forPP}ro Ttte <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight age rn—d—ic4ted _ Date Tested <br /> LIVLEADED TIGHT 7 02-17-186 <br /> This is to certify that these tank systems were tested on the date(s)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> 02-17-89 BILL CAMPBELL PETRO-CHECK, INC. &," <br /> Date Testing Contractor or Company. By:• Signature ' <br /> 1854 414811816 271 Opportunity St., Ste. C, Sacramento, d 95838 <br /> Senal No of Thermal Technicians Address <br /> Sensor <br />