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ata Cart for Tank sy s i m T Iness `Test <br />�� <br />FEB 1 ;. <br />PLEASE PRINT ctul ONNIENTAL HEALT�_. <br />1. OWNER Property [ <br />'tank (s) <br />tire" t, <br />Name Address Flepresen+ahve Telephone <br />Name Address Representative Telephone <br />2. OPERATOR <br />A� f 3 CIF, t.�� 24 N , <br />Name Address Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />M Fo S 1 N S .4 4 n1 <br />- <br />4, WHO REQUESTED <br />TEST AND WHEN <br />Name Title company or Affiliation Date <br />Address Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifotded tanks <br />Identity by Direction Capacity <br />Brsnd/Supplim <br />Grade <br />Approx. Age Steal/Fiberglass <br />f z <br />1r/4 T >r rt a-5 -r <br />S Li PER [!r1 L <br />a P] —47 - r-, L <br />A 7. `, T_I <br />AJ � 4 CA 4 <br />.r k <br />1J — 0 0 <br />)Aj a P, 1`1-s <br />I.ias� ori <br />, <br />r � <br />6. INSTALLATION <br />DATA <br />Location Cover <br />North Inside driveway, Concrete, Black Top. <br />Rear of station, etc. €ar h, atc, <br />Fills <br />Size, Titefill make, rop <br />tubes, Remole Fills /.JO <br />Vents <br />t <br />Size, Manilolded/V 4 <br />Siphones Pumps <br />N)A JA. c Ka r <br />Suction, Remote, <br />Which lank$? Make it known <br />7. UNDERGROUND <br />WATER <br />Is the water overthetank? <br />Depth to the Nater tabl. L2 SLE 6 L-L��i t AtJjh� LJ Yes <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name Telephone <br />Extra product to `top ofr and run tank tester. How and who 10 pfovide? Conalder NO Lead <br />Terminal or other contact <br />tar inquiry <br />notice or <br />.oNr1 W nY Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />Paradiso Construction Colt <br />- <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />Additional information on any hems above. Officials or others to be advised when teeing is In progress or compietad. Visitors or observers present during last, ate. <br />11. TEST RESULTS <br />Testa were made on the above tank systems In accordance with test procedures prescribed for <br />as defatted on etltached test charts with results as Wows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />3 w6" <br />12. SENSOR <br />CERTIFICATION <br />13. This is to comity am two twfk sydwn wan tfileted on she dates) shown. Those kKlcmW ss "%hr meet the attarta established by the <br />NMkNW Fire Peron mod <br />TachnicNns <br />Lip F, Paradiso Constructio Co. <br />1 p - <br />Testing Contractor or Company. By: fur <br />jW 12251 094(3 <br />rAvdfruW 9220 "G" Street. Oakland- CA 446M _--- <br />Dela <br />Swint No. of Tnarm.l <br />z STXa rs pa `, fA <br />c.runcrtfon e ; Z + /Q ZA <br />Addrars <br />PN6827 <br />