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RECEIVE ) Data Chart for Tank System Tightness Test <br />NOV 8 1989 <br />pFEARE PRINTENVIRONMENTAL HEALTH <br />1. <br />OWNER Frowdit❑ <br />Tarkry) ❑ <br />'W410 71— q& l SQ Z ;5 U zAri <br />G TO CK7b iU C_.-_ A - <br />Name Addrer <br />ReptwtletM ieleonona <br />WIa Adiseee <br />nwm mm t Telepnnne <br />2. <br />OPERATOR <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />Tv& T <br />�L <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />N°"'° TMb <br />Company orAtlllifelen Deist <br />Addran <br />Telephone <br />5, <br />TANKINVOLVED <br />tba additional Ilnae <br />for manlfolded tricks <br />Identify by Olracka, Caaetly BrerM/Buppllw (ketln <br />Approx. Asa SteNIFlbmim <br />EAST /Z, al) 0 <br />g <br />6, <br />INSTALLATION <br />Location Oovan FIM Vnnh Siphon Purnq <br />I VE SLA', CD11G(a_-iYL <br />��/it73INE: <br />tbnh inside drhewey. Concrete. Bleck Top, She, TBRn1 make, Drop Suction, Rpmots. <br />Rxpr of shalon, to Earth, atc. Wbae. Rent. Fllb M.. Mealfplded reach tMkii Make If known <br />7. <br />UNDERGROUND <br />WATER <br />A <br />Depth tithe Wates tarts I � <br />bnest webr warma tenkT <br />1:1y. Mie, <br />6. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be tilled hr. DO, Arranged by <br />Entre product to'Tep ofr eM run tank tester. lbw art who 1p ppNde7 Conaldn NO Lmd. <br />Name Telephone <br />TarmbM oronqu tooted . = eIe-rvN <br />for rinse or IngRry <br />contains <br />Nems Telephone <br />9. <br />CONTRACTOR, <br />MECHANICS, <br />any other connector <br />Insolent <br />r M P�ASS�YT <br />10. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />_R1_G011 )z /N� rsoLA a r�.� > �NZ-w QN <br />E D S6 <br />Addelenel Information on airy asms ;Dove. Off n.l. or others to he advleee when testing is In program; or complateri Manua or oDssners present during teat, On <br />11. <br />TEST RESULTS <br />Tela ware meth an the above tank syMeme In scope do c s yHlh test procedure prescribed for <br />a d"lsd on atl adfrW test Charlie With n lts as Waves. <br />Tank Idennllptbn Tight Leakage Indicewd OM` Ta <br />NL 1♦c / <br />GP/I 7 r G <br />12. SENSOR <br />CERTIFICATION <br />Deft <br />90 <br />Betel No. of Thermal - <br />13. This I, to cwft that Nes tank systems were tasted can the dele(s) shown. Thee Indicated as -Nhr meet the criteria aatablbtwd by Rw <br />tonal Firs Protaeuon Aaodallon Pamphlet 928. <br />ecnmclenr F� / �� �j <br />�.y�lBASSE i i C0iqsTRjjcTjw, any. any. By By: Signature <br />CwnncRlon, �+E1 e— /03a Callfomia Lic. #394896 <br />z FAIR OAKS. CAL I MR= 09" <br />(916) 967-7424 <br />Cacigonhoc 0 - PNPP?r <br />a <br />It <br />