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PLEASE MINT <br />TAW TEW <br />1• OWNER pfflp" ❑ M.co P.O. Box 5811 San Mateo, Caei.6. 94402 Ron Mit" 1-500-421-7457 <br />Telephone <br />ItepnwnIOU" <br />Telephone <br />.2. OPERATOR ARCO 11548, 1612 hammer Ln. /Brentwood, Stockton, CA <br />akea.e -- -----------------_ ....-- <br />3. REASON FORTo Check ohtghZn2b4 Teephone <br />TEST – — - _ <br />(Explain Fully' <br />4. WHO REQUESTED Ron Mei a Akco <br />TEST AND WHEN p•®, Box 551 94402 _ Tame <br />ws Telephone <br />S. WHO IS PAYING Ron Mite,6 <br />FOR THIS TEST?Tame <br />• 'S San Mateo, 'a 94402 `"" Telephone <br />6. TANK(S) INVOLVEO <br />7. INSTALLATION <br />DATA <br />8. UNDERGROUND <br />WATER <br />9. FILL -UP <br />ARRANGEMENTS <br />10. CONTRACTOR. <br />MECHANICS. <br />MW ~ contractor <br />indafred <br />11. OTHER <br />INFORMATION <br />OR REMARKS <br />': Qnw AAi pea <br />MUMV by 0imselim <br />Cgwc*V <br />G olle� � <br />AOpro°. AQe <br />S /fibatgfass <br />LoeatanSiphons <br />Maf <br />Covet <br />onk Nee. Top. <br />Fill& <br />Silo. YMWtN make. trop <br />WOss. ftemo% Has <br />Vents <br />Siso. Mo'MfolAeO <br />Which tanks t <br />Pumps <br />Sot fon. MmMe. <br />Make N knoweh <br />Depth to the WOW table ( // t A <br />Tanks to b@ find M. Date Hanged by <br />Exue product to "tap OW end run TETT. Now and who to provide 7 Consklef NO Lead. Nem. <br />Is she WMW Over the tank 7 <br />❑ Yes ❑ No <br />Telephone <br />Tonninal of o0w contact <br />for notice or iltpuity <br />%ompf" Nome Telephone <br />—man wwonnstan on any Rome bolo. offioiele Of Othersa a edvesed when tear <br />doting test etc. ng is in p(Ogfeas of completed. Visitors or obsemers present <br />12. TEST RESULTS TOO" wrov nova On delleNed � M with lest ptooidlmm fof T1iS' <br />Nat chaos with essults as fonows: <br />Tank Identification Tight Leakage Indicated Oat@ Tested <br />-77 <br />13. CERTIFICATION TM` w N 0"Mb a"t a"" w ft VMS on"doWs) •town. Tho" as -Tight" mast ata theft as• <br />Ftt+ Pwn~ 3". / r <br />LCI <br />o.N <br />/i 1l�R 1 1 Zi.7 ,n T Teatinp omfaclof of mpane, v= wa <br />