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Data Chc*for Tank System Tightneo Test <br /> CHAMPION'S PRECISION TANK TESTIM <br /> 1451 Oakhurst Way, Sacramcnto, CA 95822 <br /> Fl PRINT <br /> 1. OWNER fe,ope"v ❑ Lodi Memorial Hospital 975 S. Fairmont, Lodi. Califoria <br /> AOO,est Jim Blais 209"' 4t"3"411 Isiepwo-.0 <br /> 2. OPERATOR <br /> None Address Taepnona <br /> 3. REASON FOR RB313LATION GOVERNING UNDOn ZARDDIS SIMSTANCFS <br /> TEST _�IJ QUND_SpAGE <br /> TER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE CODE <br /> ERCM _ <br /> (Explain Fully) <br /> 4. WHO REQUESTED OWNER <br /> TEST AND WHEN Name Trtte Comcienfr or Aflowtion Cialf <br /> A0Gl.s% Telephone <br /> 5. WHO IS PAYING (1101TV'D <br /> FOR THIS TEST? 'V51;W`i`V1.Agency or Ino—cf.al Person Authorizing Title telephone <br /> Billing Addiest, C,lv State Zip <br /> Attention of O'er,No Other InIlwel'ons <br /> Identify by Direction Capacity Brand,!Supphef Grade Approx Age Steel/Fiberglass6. TANK(S) INVOLVED <br /> c' n0(,jj, STe-_fe <br /> Location Cover Fills Vents Siphortes Pumps <br /> 7. INSTALLATION k Re Min 7C <br /> DATA <br /> North Inside dntlawar. Concrete Black TopSize.Titefol make.DIOD Suction,Remote. <br /> Rearof station,etc Earth.etc tubes Remote Fills Size Mondolde"d Which tanks I Make if known <br /> 8. UNDERGROUND Is the water over the tank 7 <br /> WATER Depth to the Water table El Yes ❑ No <br /> 9. FILL-UP Tanks to be filled_he —Dale Arranged by TeieDhons <br /> ARRANGEMENTS Extra product to"top off"and run TSTT How and who to provide 7 Consider NO Lead <br /> Terminal or other contact <br /> for notice of inquiry <br /> Name Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any te—s above Off,C,81S or others 10 be advised when testing is in progress of completed Visitors or observers present <br /> during test etc <br /> Tests were made on the above tank Systems in SOCCordance with test procedures prescribed for Horner Ezy-Chek <br /> 12. TEST RESULTS as detailed on attached test Charts with results as follows <br /> I I <br /> Tank Identification I T.g.,! Leakage Indicated Date Tested <br /> This is to Certify that these tank systems were tested on the dater(s)shown Those indicated as meet the criterns established by <br /> 13. CERTIFICATION the National Fire Protection Asorcistion Pamphlet 3M <br /> 2-1-90 <br /> Date Clinton Denman CHAMPION'S PRECISION TANK TESTING <br /> 2452 OAKHUP1.1"'co-a".,or co-pa,,, 8, Signal- <br /> 90-1323 WAY, SACRAYAEN'TO, CA 95822 <br /> or T,,._., SA00,#%, <br /> S&ns& <br />