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CHAMPION PRECISION TASL TESTING: <br />DATA ART FOR PETRO—TITS TANK SWEK TIGHTNESS TEST: <br />P.O._BOR 13059 SACRAMENTO, CALIF. 95813-3059 <br />PLEASE PRINT CALIF: 1-800-660-9443 NEV. 1-800-949-9443 (916) 927-1557 <br />1. OWNER Property ❑ <br />Name Address Zip Representative Tolepnon <br />Tank(S) <br />Nano Address Zip Representative Telephone <br />2. OPERATOR -Wfil l L L U R 2512 WATERLOO ROAD SlOCKTON CALIF <br />NaAddress Zip TeN <br />na phone <br />3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS S ST CES <br />TEST SUBCHAPTER 16 `-CH ER 3 TITLE 23 OF CALIFORNIA ADMINISTRATIVE CODE: <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />ti <br />5. TANK INVOLVED NOR <br />NOR <br />ties addittiond lines NOR <br />for manUdded tanks <br />6. INSTALLATION <br />DATA <br />7. UNDERGROUND <br />WATER <br />8. FILL -UP <br />ARRANGEMENTS <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />11. TEST METHOD <br />11 a. TEST RESULTS <br />12. SENSOR <br />CERTIFICATION <br />1/23/92 <br />ore <br />rdle <br />Address zip <br />Brand pplier Grade <br />T; <br />L,ompany or nnn.m�m. <br />Location <br />Cover <br />Fills <br />Vents <br />Siphons Pumps <br />WEST <br />BLACKTOP <br />4" WI T# <br />2" <br />RCN <br />OF <br />AND <br />OVERFILL <br />914CKET <br />STORE <br />CONCRETE <br />PROTECTION <br />TURBINE <br />basith to the water table from craft BELOW <br />TANK <br />Is the water over the tank? <br />0— ❑No WELL POINT [X] <br />TANK(S) TO BE FILLED: 0700 HR • 5110194 DATE <br />Extra product to 'top otr and run tank tester. Mow and who to provide? Consider NO t.aad. <br />TESTING CO. <br />Terminal of other contact <br />for notice or inquiry <br />Company Name Telephone <br />Additional information on any items above. Officials or others to be advised when testing is in progress Or completed. Visitors Or observers present during test, etc. <br />0 PETRO TITE # 2 0 SELF LEVELING STANDPIPE AND DTS. 2,000 <br />Tests were made on the above tank systems M accordance with test procedures prescribed for <br />as detailed on attached test charts with results as . <br />Tarte Identification Tight Net Volume Change Per Hour Date Tested <br />PAss /0 4 <br />r/ r -.o34 511oJ94 <br />rDIESEL o <br />Technicians <br />t WILLIAM R. CAMPBELL CHAMPION PRECISION TANK TESTING <br />CA. 92-1324 1554 JULIESSE ST. <br />CMtlautlon r <br />WILLIAM R. CAMPBELL SACRAM NTO, CALIF. 95813-3059 <br />2 <br />Cartification <br />, NEV. UTT-1010 <br />