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39-x94 <br />PLASE PRINT <br />-ssesse <br />1. OWNER Property <br />Tanks) <br />2. OPERATOR <br />Data Ch t for Tank System Tightnt*A �stA,p 2,� j;87 V <br />ptf ro nt—e <br />TANK TESTER MEN?A(- HEALT" <br />Glasrock Home Hedlth Care,705 Ind. Park Dr. F 3ca, Ca. <br />Name Adarsas n ro o C ReO timmunive f"'00'9 9'1' ePTLg1. <br />Taranto.. <br />3. <br />REASON FOR <br />TEST <br />— – <br />dal i fnrni a qtq t Taw <br />---- -- -- <br />(Explain Fully) <br />_ <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Rick VoRet @10-:30 <br />Name Tina <br />Aderesn <br />_____ <br />Continent, or ANilmtion Oate <br />Telephone <br />5. <br />WHO IS PAYING <br />FOR THIS TEST? <br />ork_EQIDa�� <br />ealtYLareF. 705 <br />C p0 Agen el P .... n AWhpnzing <br />�.�._ T°�C <br />Billing Address Cry <br />Attention of: Ores No. <br />Mantica <br />Park Dr - <br />Ind, Cam_ <br />�� <br />Title ca, <br />State Zip <br />Otnw Inumalona <br />B. <br />TANK(S) INVOLVED <br />Identify by Direction <br />_4252007 <br />Capacity <br />__ <br />Brand/Supplier <br />Grace <br />—Unl__ <br />Approx. Age <br />Steal/Fiberglass <br />- <br />7. <br />INSTALLATION <br />DATA <br />Location <br />s„�/tww <br />.Z <br />North inside driveway. <br />Rear of ush.m, ata <br />Cover <br />B.T. <br />Concrete <br />Comate. Black Top, <br />4th, eta <br />Fills <br />of <br />Sim, Td.1.11 next. 0100 <br />.be,, Remote Fills <br />Vents <br />2te <br />Site. Msnit.rded <br />Siphons <br />N" <br />Winch tanks 1 <br />Pumps. <br />G dbo <br />Suotion <br />Suction, Remote. <br />rattail knew. <br />8. <br />UNDERGROUND <br />WATER <br />Depth to the Water table <br />Is th�e water over the lank? <br />rU Yes ® No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled_ hr. Data Anangedby <br />Extra product to "top on" and Inn TSTT. How and who to provide? <br />Mobil Jobber Tank W gores <br />(*P.Orge W Lownr. <br />ry T(20o)K4K_0!79 <br />N.me el.p inn. <br />Consider NO Lead. <br />Terminal or other contact <br />lot notice or inquiry <br />Company <br />Name Telephone <br />10. <br />CONTRACTOR, <br />MECHANICS. <br />— — <br />-- -- <br />any other contractor <br />Involved <br />-- <br />11. <br />OTHER <br />INFORMATION <br />OR REMARKS_ <br />Additional mtormation on any nems above. Officials or others to be advised when testing is In 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 w4 Td <br />as detailed on attached test charts with results as follows: r,—rtsR <br />Tank Identification Tight Leakage Indicated Date Tested <br />Passed'— <br />Failed <br />Cert. <br />Copy <br />— <br />Paid <br />Charg <br />Inv. <br />County <br />