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I <br />PLEASE PRINT <br />I. OWNER property <br />Tank(s) <br />2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Udta Oion for iam system 119niness lest <br />Irmo T <br />ppSTER <br />Arcco _ P.O. Box 5811 San Mateo, Ca j6. 94402 Ron M.itu 1-800-421-7457 <br />Nam* Address -- —------- -----_----- <br />Represent*tiw Tet*phone <br />AddressRepreseritetive telephone <br />ARCO #548, 1 12 Hammer Lane/Brentwood, Stockton, CA <br />Nam. — Address — ---------------- ---- — <br />M.. <br />--- <br />P.O. Box 5811 San Mates," Caei.sonnia 94402 Cancan"« <br />Gam <br />Tel.r <br />5. WHO IS PAYING <br />Rnco Ron M,itu <br />FOR THIS TEST? <br />ffffd5'8""'' San Mateo, %cilia 94402 <br />T"" <br />Game <br />T•"s^d^• <br />Bi1Nne Address <br />City <br />Stat* <br />zip <br />AKention of :Roo UYPA Order No. OtMr Instructions <br />kl*nW by Direction Capoeity Brand/Supplies Grade <br />Approx. Age <br />Steess <br />l/FiberglaL <br />6. TANK(S) INVOLVED <br />O° <br />S <br />t <br />ST..eee. <br />� <br />✓ <br />v <br />Location Cover Fill Vents <br />Settf 4 6,( W_ 4 <br />Sipf <br />oare rt* <br />�Gp <br />7. INSTALLATION <br />DATA <br />Y y <br />,�„6""' <br />North Inside driveway. Concrete, Black Top, Size, Titefill make, Drop <br />Rear of stetson, elt. Will. etc. tubes, Remote Fills Sae, MaMfOWed <br />Suction, Remote, <br />8. UNDERGROUND <br />Which tanks l <br />Make If known <br />WATER <br />/ <br />Depth to the water tabs. / f <br />Is the water over <br />the tank? <br />— <br />[:] Yes <br />No <br />9. FILL -UP <br />Tanks to be Hued Data Arranged by eJd !I <br />ARRANGEMENTS <br />Extra Name <br />Product to "top off" and run TSTT. How and who to provide? Consider NO Load. <br />Telephone <br />Terminal or other contact <br />— <br />for notice or inquiry <br />Company Name <br />Telephone <br />10. CONTRACTOR, <br />MECHANICS. <br />any other contractor <br />involved <br />— e <br />11. OTHER <br />INFORMATION <br />OR REMARKS <br />Additional information on any kerma above. Officials of others to be advised when testing is in progress or completed. Visitors <br />during test etc. <br />Tests wet- made on the above tank systems in accordance with test procedures prescribed for C <br />as detailed an attached <br />or believers; present <br />12. TEST RESULTS <br />test charts with results as follows: <br />Tank Identification Tight Leakage indicated <br />Date Tested <br />Q 0 <br />- b <br />13. CERTIFICATION This 'atO oir" "tit Mese• tank syaterns Were tooted on the dal -(s) shown. Those fndkated as"Tight" me -t the criteria estaiHishod by <br />the National Fla Protection AsoelatIon Pernphist 329. <br />Oslo LCI <br />o- g( 9�/ Testing Contractor or Company. By: ipnaWre <br />i ------ _.a 7 41481 1367 P n R,,., ,-,n„ � - r _ _ <br />