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Data Chart for Tank System Tightness Test <br /> ppfro nt—e <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ Geweke Ford- teff Stublefield (209 )466-8571Ext:520 <br /> Tankte) TU45 South Cherokee Lan Lodi, CA 95241 r.•.n.1i.a trillion... <br /> Name Address Representative Telephone <br /> 2. OPERATOR Geweke Ford - 1045 South Cherokee Lane Lodi CA <br /> Name Address Telephone <br /> 3. REASON FOR Regulations governing underground storage of hazardous <br /> TE@T substances, subchapter 16 of chapter 3 of title 23 of the <br /> (Explain Fully) California m n strat on o e . <br /> 4. WHO REQUESTED teff Stublefield9 Geweke Ford 7/30/87 <br /> TEST AND WHEN ima4 South h r TItM 5240Company or Affiliation Dm <br /> Address Telephone <br /> 5. WHO IS PAYING Geweke Ford2 teff Stublefield (209)466-8571 <br /> FOR THIS TEST? Compare Agency or Individual Pe son AUmorbin Title Telephone <br /> Billing Address CItY Sure Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Gra Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED 000 S4RAL <br /> 2 o0U 'I r Sf�L 1 <br /> Location Clover Fills Vents Siphons Pumps <br /> 7. DATA INSTALLATION a0r,`r, 0, `� � 'Oy/L Z I t ��/ 44 I <br /> Nonh Inside driveway. Concrete.Bleck Top. Size,Tiblrll make.Drop 1/Z�Z Suasion,Remote. <br /> Ren of station,etc. Earth,e11, topes.Demote Fills Size.Manifold Which ranks 7 Make 11 known <br /> 6. UNDERGROUND ��� Is the water over the tank? <br /> WATER Depth to the water table. 'd fah ❑ res No <br /> Tanks to be filled hr. — I Date Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off'and ru TS1T. How and who to provide 7 Consider NO Lead. <br /> Terminal or other contact _ <br /> for notice or inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR, O Nl — <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER Ne <br /> INFORMATI N a <br /> g� q Additional information on any items above.Officials or others to be advised when testing is in progress or completed.Wsitois or observers pesent <br /> V 1 during test etc. <br /> Tests were made on the stop"tank systems In accordance with test procedures prescribed for .FO j11P <br /> A�Gff�T l6 rs as detelled on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Dale Tested <br /> ENVIROMENTAL HEALTH .01 A-R__ <br /> PERMIT/SERVICES <br /> This Is to Carl that these tank systems were tested on the details)shown,Those Indicated as"TIghP'iIIRlnifla Alwle established by <br /> 13. CERTIFICATION the Wtionsf Fire Protection Asociatlun Pamphlet 029. <br /> ` 7 $7 k>k /1 NORTH CAL__�C}—ONSTRUlCDC <br /> 7;s <br /> • __7 St VtE1CC '-1" 9— i n..... ore <br /> m y. <br /> FSo nn <br /> Cvc)K <br /> -- ---- - <br /> ~fnu Fk�t't�i� _ ._ ... ' -lnhnni•n� � .._._.. - SIOCktOns�95,�---__.Aad <br /> Sensor <br />