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DaF'rt for Tank System ,���ss Test?' <br />�Tite ,4 <br />PLEASE PRINT K <br />1. <br />OWNER Property ❑ <br />Tank(:) 13 <br />DSS Engineering contractors 3oyc Groves.<M-. :948-0302 <br />639 W. ' ClayStockton"95206 �`~''""�"r"a`• x 5= xa�,� rw,Mon. <br />Name Telephone <br />2. <br />OPERATOR <br />- ;• . '�� .�:,����-.,:.�,�.�. ., �.�., .��...: --, <br />Name . Address Telephone <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />Regulations governingunderground storage . o " hazar ous <br />substances, subchapter 16 of chapter -3 of. ttle- -o <br />the California Administration Co e. <br />4. <br />. <br />WHO REQUESTED <br />TEST AND WHEN <br />Boyd Groves Manager :. . <br />Name p <br />Title nr a rt�ry(fatlef{ 5 2 0 7 9 4 if— <br />639 W. Clay P.O. Box 7838 Stock, 5 * 3 0 <br />Telephone <br />- - Address Telephone <br />WHO IS PAYINGDDS <br />Engineering Contractors <br />5. <br />FOR THIS TEST? <br />5empn:•69encvg, f v107'8 3 8 Person AMndkton CAMS 5 2 0 6 Telephone <br />Billing Address City State zip <br />Attention of: - Order No. Other Inductions . <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />. CapacityBand/Supplier <br />: <br />Grade ; ;,r; <br />-, !Approx. Age .,> <br />Steel/Fiberglass <br />WE&P' <br />7. <br />INSTALLATION <br />DATA <br />Location <br />t�A40 <br />Nonh Inside driveway, <br />Rear of station, etc. <br />Cover <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />Size, Thefill make, Drop <br />tubes, Remote Fills <br />'Yenta <br />Sue. Manifolded <br />Siphons <br />Which tanks 7 <br />Pumps . <br />-.� Suction, Remote, <br />Make If known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table " ❑ yes ❑ No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />- <br />Tanks to be filled hr. Date Arranged by Telephone <br />Name <br />Extra product to "top off- and run TSTT. How and who to provide? , ': Consider NO Load. <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. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />, <br />/ "IMC, /= L OC:iDl< <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers presen <br />during test etc. <br />12. <br />TEST RESULTS <br />Tests were mads on the above tank systems in accordance with lost procedures prescrlbed for . <br />as detailed on attached test merle with results as follows <br />Tank Identification Tight Leakage Indicated Dau Tested <br />7 <br />3 <br />In o S- <br />—� <br />