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000 ®®® PLEASE PRINT <br />1. 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 />5. WHO IS PAYING <br />FOR THIS TESTI <br />Data r 1' Tank1 <br />hb-Less lestretro de <br />TANK TESTER <br />Quik Stop Markets, <br />Inc. P.O. Box 5745 <br />Fremont, <br />Ca., 94537 <br />`V. Jack Griffith <br />A\®T15) 657-6500 <br />Rap"aM"Ove <br />Telephone <br />Name <br />Address <br />Repteantative <br />Telephone <br />Name <br />State and County Regulations <br />Name Tine <br />Same <br />Address <br />Same <br />Company. Agency at Individual Peron Aunweitlnn <br />Billing Address City <br />Attention of: Otdar No. <br />ray <br />k1 <br />Dow <br />fO <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Ape <br />Steel/Fiberglass <br />6. TANK(S)INVOLVED <br />/< <br />Location <br />Cover <br />Fills <br />Vent <br />Sipiotsas <br />Pumps <br />7. INSTALLATION <br />DATA <br />North inside driveway, <br />Rest of station, etc. <br />Concrete, Black Top. <br />I Earth, etc. <br />Site, Thertill maks, Drop <br />I tubes. Remote Fills <br />Site, Menirolded <br />Which tanks r <br />Suction, Remote. <br />Make it known <br />8. UNDERGROUND �� I Is the water over the tank r <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 oft" and tun TSTT. How and who to provide P Consider NO Load. <br />Terminal or other contact <br />for notice or in®utry <br />Company Name Telephone <br />10. CONTRACTOR, <br />MECHANICS. <br />any other contractor I <br />involved <br />11. OTHER <br />INFORMATION <br />OR REMARKS ----- <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors tN observers present <br />during test etc. <br />Tests were made on the above tank systems in accordance with lost procedures prescribed for waro <br />Tjjr <br />12. TEST RESULTS as detailed on attached test charts with results as follows: <br />Tank Identification , ' Tight I Leakage Indicated ( Data Tested <br />w.it 10 1✓ 1 -- ♦< __ P L l i —zo—so 7 <br />This is to certify that tMso tank systems were tested on the date(s) shown. Those Indicated as '719 1" meet the critwla established by <br />13. CERTIFICATION the National Firs Protection Asocistion Pamphlet 329. <br />/—zo—.9-1 J. Nestor Bay City Testin , Inc. <br />Dar Testing Contractor or Company. Signahne <br />See test _ <br />Setuil No of Thermal Technicians las <br />