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IIIIIII� Champion <br /> Precision Tank Testing <br /> License No73`J'78 Data Chart for Tank System Tightness Test <br /> . <br /> PLEASE PRINT <br /> 1, OWNER Pr.pLl Sumgje-sr Glouors SQ/ HwV /Z Gacv/! Gar <br /> M. Addrea Zip ' RaPra tante Telapnona <br /> Tara,El <br /> Name Adore, Zip Represanlauva Telephone <br /> 2. OPERATOR wma Address Zip <br /> Twpnona <br /> 3. REASON FOR REGULATIONS GOVERNING UNDERGROUND STORAGE OF HARDOUS SUBSTANCES SUBSTANCES <br /> TEST SUBCHAPTER 16 OF CHAPTER 3 TITLE 23 OF CALIFORNIA ADMINISTRATIVE CODE. <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Na. Title company or Aailiauon Data <br /> "asks Zip Tal"hone <br /> genua,M Draclion capacity [Ris <br /> dSupPlier Grad. Approx.Age SteellFipmglacs <br /> 5. TANK INVOLVED <br /> Gore /D fe f /C -- <br /> WeAdditicnatllnea Lnt /d, u✓�Cee t <br /> for manilnlded tants Al 0 <br /> fi YG teCL <br /> Location / Cover / Vents %Prones Pumps <br /> 8 DATA INSTALLATION Wir 5-1" Sr L✓G NG r LL <br /> G4' %faro (,D C� V10Ylt� 5�5 <br /> Norm invae driveway. Concrete.Black Top. $4e.Ttelili make.Drop Sumion,�pr• <br /> Rear of alet..etc. Eenh.Mc. tupe5.Remou Fills %=e.MiNrolded Mich tmkt' Make It a.wn <br /> 7. UNDERGROUND Is the weler o`er the tank' <br /> WATER Depth to the.aur tare Irom grade ❑yes ❑No <br /> 8. FILL-UP Tanks to w IANC r. Date Arrenged Iry <br /> Norma TaNpnone <br /> ARRANGEMENTS Enra product m lop ofr and run tank tester. More and who to Dhov,a? Consider NO Leede. <br /> TESTING COMPANY <br /> Terminal or other contacl <br /> M notice or inowry <br /> company Name Teleprone <br /> 9. CONTRACTOR, SELF LEVELING STANDPIPE AND DIS. 2,000 <br /> MECHANICS, <br /> any w1 contractor <br /> inpwd <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional NlOrrllalion on any have aoove.011iciels a mbar to de advised when tastinq'e in Drogreu or COmpNledwseon or ODSerren prnem arnq tier,elc. <br /> 11. TEST METHOD ® PETRO TITE _V7 ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Teats were made can the above tank systems In accordance with test procedures prescrloed for <br /> 11a. TEST RESULTS as detailed on aXeched last charts with results as follows: <br /> Tank IdenlifialiOn right Nat Volume chahge Per Naur ate Tested <br /> rs —. oS G.• ,H. — - <br /> /� f GS z <br /> f rS ' ode ey, C71 G, , <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION CHAMPIONS PRECISION TANK TESTING <br /> CERTIFICATION �.�. P.O. BOX 13059 <br /> Tecrrk SACRAMENTO, CALIF. 95813 <br /> Data <br /> 5.1.1 Na of Thwmel certlllratbn. <br /> �11??1-B-Q33Z pa p Conbac o IX CdnpanY. 9Y: sVnatun <br /> s«.w : las �SfrtitG �3 I�ZS (916)927-1557 CALIF. "°°Y 800-660-9443 <br /> HEY. 1-800-949-9443 <br /> Gerefkaana PN6 27 <br />