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zot <br />L �t/ I a 6 j <br />Nov 8 1989 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />PLEASE PRINT <br />Data Chart for Tank System Tightness Test <br />1. <br />OWNER Regedy0 <br />Tar l ❑ <br />UIV04-14`7/9 ISQ"Z_ F[-- QiZAV49 �J% t1Gi�rB/�% efb. <br />Na. AM. RepwaactatNa Telephone <br />Name Addreas Represented. <br />Telephone <br />2. <br />OPERATOR <br />Name "do". <br />Taepherro <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />U 124 AC 14 M [ LDU U <br />-7-0 <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Make — Tat° Company, w Affiliation <br />Data <br />Addreka <br />Telephone <br />5. <br />TANK INVOLVED <br />Ilr eddebMl IInM <br />M manlldded tank$ <br />Identify M Dlrectron capacity Brend/Suppliar <br />G,.de Apo.. Ape <br />srealiFipe,gl.ss <br />E p <br />- <br />_ <br />8. <br />INSTALLATION <br />DATA <br />London Coyer Fhn. <br />� 5LA,-g CDNey>✓..'� <br />Norte Inelda driveway, Concrete, Black Top, Size, Tltenll make, Drop <br />Row M Mallon, etc. Earn, etc. torte. Remote Mile <br />vent. Space. <br />Sire, Manllolded Which tank.' <br />Pumps <br />I u�b!P,)-r <br />Suction, Remote, <br />Make If known <br />7. <br />UNDERGROUNDla <br />WATER <br />Inn wet., n.er the I.nk4 <br />D Toth to ne Water table 13 <br />8. <br />FILL -UP <br />ARRANGEMENTS <br />Tank, to be 1111M hr. Dale Arranged by Name <br />E." product to Yop offand ma tank tens. Now, and who W pmNgeT Comte.. No Lead. <br />Telephone <br />Terminal or Darer <br />ryn UAJ06AL -..- STo GV_7'ON <br />1w nodn a Ineulry - — <br />Cpmperry Nano <br />_ <br />Telephone <br />9. <br />CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />m <br />_ <br />10. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />Additional Information on any Item. above. Mideie or others to be advised when laming Is In proprea or cemplsted. Vkegre or obeayera postal durlrp tee. me, <br />11. <br />TEST RESULTS <br />Torte were Mede on the abors tank systema In axordenos wNh had procedures preek: bed for <br />s EstaBed on attached teat chert with reaulta ee follow$: <br />Tank Idendn w rgM Leakage Indicated Date Teeted <br />OG"r <br />12. SENSOR <br />CERTIFICATION <br />/} 7� <br />�j <br />eats No.a TMrma1 <br />13. This te to nNthly that these tank systems ware heated on the date(s) $howm. Tubae Indicated . -TVhr meet the taftede eatsbN.h rd by the <br />NIUMMI Ray Protection Asaoetedon Pamphlet 3n <br />acnnlmem <br />aap�p r OT7� BASSETT COI i't�i.`rfIDA"rie "y <br />rsuse.ea.l„ 1 I.. *�"IgOaI4 <br />a <br />cwdeoatlwt a <br />1130 feenrl g8 WayAddnw <br />FAIR OAKS, CALIFORNIA 9562, <br />(916) 967-7424 <br />MM2T <br />r <br />