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Data Art for Tank System TightlOss Test <br /> PLEASE PRINT PE -CHECK INC. <br /> L J L <br /> � <br /> 1. OWNER Property ❑ DAY'S BAIT & TACKLE 5611 WATERLOO ROAD, STOCKTON, CA 95205 <br /> ❑ Name Address Representative Telephone <br /> Tank(s) nA3ZP. AIM LIMA _ <br /> 9-41-9949 <br /> Name Address Representative Telephone <br /> 2. OPERATOR SAME <br /> Name Address Telephone <br /> 3. REASON FOR REGULATION <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 Company or Affilulion 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 N/S WEST 8,000 REGULAR <br /> N/S CENTER 10,000 DIESEL <br /> N/S EAST 12,000 UNLEADED <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION EAST SIDE OF BLACKTOP 41t OVERFLOW 211 YES RED JACKET <br /> DATA STORE <br /> TURBINE <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 it 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 JOA UIN COUNTY V <br /> Additional information on any Mems 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 for "_Piro T 4_h <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: °'M <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> REGULAR — --- 06-12-8§ <br /> DIESEL <br /> -12- <br /> DIESEL TIGHT 18 06-12-89 <br /> UNLEADED TIGHT -.044 06-12-89 <br /> _ 1 <br /> This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight'meet the criteria setablttthed <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. n <br /> 06-12-89 WILLIAM CAMPBELL PETRO-CHECK, INC. <br /> Date Testing Contractor or Company. By: Signature <br /> 1819; 1972; 1854 414811816 2076 Acoma Street, Sacramento, CA 9tiR1.5 <br /> Sena]No.of Thermal Technicians Address <br /> Sense <br />