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Dara Chart 9©r Tank Systerr"'ightness Test <br />PLEASE PRINT <br />1. OWNER ...,.., ❑ <br />}NI.I ❑ <br />r.n,. .. IWOrw ZW <br />Ap—w,re.. T.rFnen. <br />M.,w. .be.w 2�0 <br />rluor�wr.n.. T.I..ww <br />2. OPERATOR <br />1 . FeB <br />v -+Ix- <br />M.p. MCrw ZIP <br />TMpwy <br />3. REASON FOR <br />TEST <br />(Em FWIj) <br />REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBSTANCES SUBCHAPTER <br />16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE CODE <br />4. WHO REQUESTED <br />TEST AND WHEN <br />"'^ r.r <br />tapowr p n...Im dr <br />Aaais ZIP <br />S. TANK INVOLVED <br />u..alrlon.l Im.. <br />4 m✓:Ma.a uN. <br />lower. A Oir +ion Co. - br.arswv�+ Cr.M <br />G) w lcm zke�L <br />Nop Aa S�mvFewpla <br />V, <br />11 � <br />6 INSTALLATION <br />DATA <br />1p y,w Cmw Filb V. Sq.pa �pl,p. <br />-Qe;eh� uF1 <br />wm r.e. p:—a. Cwcrw.. Bra r.o. Si[.. TIMF pW. GW screen 14ror. <br />pW pr lrlcn. .lc EY0r. .1c mem. Pwor Filr 9(.. WMJIEM Wlritll Mbf yy. I bmwr <br />7. UNDERGROUND <br />WATER <br />oiignfo .r.rel.Irw�gr T)IA -Vsnllr S - <br />r°r-w wwltiw.t <br />❑rm ❑rm <br />8. FILL-UP <br />ARRANGEMENTS <br />/^.DIU) <br />TVYube. bl.CT.L'�62N.—15i•-1..1I wr Ar.1 <br />E.e. poen m �.o or wa mn Iw. rw. Mo. w .Im m ppi0.t emue.r ero �..e <br />T1 <br />TwnN p aarw more <br />m. rwem «.w.r <br />CowpwrT <br />rw r.IMw. <br />9. CONTRACTOR, <br />MECHANICS, <br />wr pIr CMIr.e« <br />Yno1..J <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />- <br />AE01...• inlwmtl9n w-yw�-Y i\.m..Ww 011i[,Nr p pM. b G .h,YU �e.n Iwo � 11 «.Oryv p mr^Vlb.l. W,IT p OO.wwr. p.r.r. Mwq rM. .l<. <br />11. TEST METHOD <br />PETRO TITf— <br />❑ PETRO COMP <br />❑ OUICK CHECK 2000 <br />11a. TEST RESULTS <br />Tib w.. w.a.. "Sa d,,l, att cAW I"I chr Mur..r+lbMill rr Imo, m ��A� lot <br />Tw lO.ner.Wbn TW ../\ WM�n. wyCe.p. h. M. Dr. Tm1.E <br />12. SENSOR <br />CERTIFICATION <br />13. CONTRACTOR CERTIFICATION <br />T� � <br />I11. �AwCEiEci CHAMPION'S PRECISION TANK TA]I )9 _ <br />iwlry Cer,Ir.cv w Crw�rv. F: Spwm <br />�.C;-l'J- D (1. RnX 1if15Q SAC.RAMFNTO- CA_ 95817-i(15Q <br />�;g <br />1-800 660-9443 <br />Jre. <br />MYZ7 <br />