Laserfiche WebLink
9f, <br />PLEASE PRINT '1 <br />Data UPart for Tank System <br />It�n'S. <br />Tighe, ess TestC Ew I "VE <br />CHAMPION r S 'r'1 TSION TANK T1; TPI G J � � '50 <br />ENVIRONMENTAL <br />ENVIRONMENTAL HL.A, . <br />1. <br />OWNER Properly ❑ <br />Southland Corp. 4558 Roseville Rd, Suite' -North Highlands, Ca'95660 <br />EN. <br />Tank(sl <br />nre Address Re wesentat, va Telephone <br />Ir _Fig <br />C�TRep,e-niiii— <br />Ndme Add, cs Telephone <br />2. <br />OPERATOR <br />�i —4 } �� 1�, -TOn <br />Name Address 7eiephone <br />3. <br />REASON FOR <br />REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS S FRSTAN,C fi <br />TEST <br />SUBCHAPTER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE COP <br />(Explain Fully` <br />4. <br />WHO REQUESTED <br />ONNER <br />TEST AND WHEN <br />Name Tole eomoanyalARJHhan oat. <br />Adotess T.I.ohone <br />5. <br />WHO IS PAYING <br />OWNER <br />FOR THIS TEST? <br />Company. Agency a, Individual Person Authorizing T.O. Telephone <br />eilhng Address City State 3rp <br />Attention of Order No. Other Insvucl.ons ` <br />6. <br />TANK{S) INVOLVED <br />Identify by Direction <br />r <br />Capacity <br />Brand/Suppllet <br />Grade <br />Approxi Age <br />I Steel/Fiberglass <br />r <br />7. <br />INSTALLATION <br />DATA <br />Location <br />North msld. driveway. <br />Rear of sta lion. etc, <br />Cover <br />Concrete. Black Too. <br />Eattn, etc. <br />Fills <br />Site, Tirelrll make. O,op <br />tuOes. Remote fills <br />veins <br />Slte. Mandold.d <br />Siphones <br />which tanks I <br />Pumps <br />Suction" Remote. <br />Make it known <br />8. <br />UNOERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table ❑ Yes ❑ No <br />�. <br />FILL UE' <br />ARRANGEMENTS <br />Tanks to be filled hr. ¢ate Arranged by <br />Name Telephone <br />Extra product to "fop off" and run TSTT. How and who to provide 7 Consider NO Lead <br />Terminal or other contact NOT APPLICABLE <br />for notice or inquiry <br />Company Name telephone <br />10. <br />CONTRACTOR. <br />MECHANICS,any other contractor <br />involved <br />NUT A?ELIGABLE_ <br />11. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />Additional Information on any items above Officials or others to be advised when testing ,s to progress or completed. Visitors or observers present <br />during test etc. <br />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for F—WL0 TA -4 <br />as detailed on attached test charts with results as follows: <br />Tankldentd.cauon Tight Leakage Indicated Date Tested <br />U rs <br />13. CERTIFICATION <br />5-21-90 <br />oat. <br />This is to certify that these tank systems were tested on the date(s) shown_ Those indicated as "Tight- meet the criteria established by <br />the National Fire Protection Asociat'ron Pamphlet 329. <br />t � .r=� CHAMPION'S PRECISION TANK TESTING <br />I Tesun Canuagar or Compan ay - 5tg a e <br />1 1451 OAKHURSI'AY r SACRAt[VTO r CA n��822 <br />