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low <br /> Data Chart for Tank jgyA, Ti ht ess Test <br /> JUN 6 4991 <br /> EASE PRINT <br /> ENVIIRONMEINTAL HEALTH <br /> 1. OWNER Propetyr�✓, C fg �FTtae� 6aoTra��C n l4 rrael Ca 4�s37(o <br /> Telesis) �l //^ y odor.,. Zip nnnrn..m,l.u.� Tnlnpbr�n� <br /> N e Address Z., Rnpresemaov. Telephone <br /> 2. OPERATOR f d CCo is ����.` .rt Eu eq <br /> Ne a <br /> Address Zip ~ Telephone <br /> 3. REASON FOR _7.2vl Kqropr� <br /> TEST _ <br /> (Explain Fully) <br /> 4. WHO REQUESTEDr4¢.r <br /> TEST AND WHEN Name nue Company or ABtM Dale <br /> 'sad Tro< dar i3/7a/ TiaerC4 53 >/� ri09-F,3/o-i��f�0 <br /> —� Address Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade APprox Age Steel/Ficerglass <br /> 5. TANK INVOLVED �;y<yolJ.�fgry�( /p�0 _._ DS.L n7-�cp,r-.f <br /> Use additional lines <br /> for manifolded tanks - ----- - <br /> Location Cover Fills Vents Slphones Pumps <br /> 6. INSTALLATION (rev, row Cma­,che F? air a" {�—. S2ce j'tmn <br /> DATA �e�rio �en. �e <br /> North Inside driveway. Concrete.Black Top, Size.Titehll make.Drop Suction,Remold. <br /> Rear o,station.etc. Earth,etc. tubes,Remote Fill, SRe.Mandolded whAh tanks' Make if known <br /> 1. UNDERGROUND IS the water over�thetank? <br /> WATER Depth to the water table from grade ❑yes �No <br /> Tanks to be linedoTo hr. 6767-80-9i -Data Arranged by ��' �?/�/A <br /> 6. FILL-UP Name - _ -Telephone <br /> ARRANGEMENTS Ext,.product to Ill otrand mn t7li ow ane who to provieev Consider NO Lead <br /> lank I 11 olP J e) ��� <br /> Terminal or ocher contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> Involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items aboveofficials or others to be advisee when testing is in progress or completed.Vis cors or observers present during test,etc. <br /> 11. TEST METHOD PETRO TITE,.Y ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Tests were made on the above tank systems In accordance with test procedures prescribed for <br /> Ila. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Not Volume Change Per Hour Date Tested <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION AFFORDA - TE$T <br /> CERTIFICATION _ <br /> 812 G STREET <br /> GALT,CA,95832 <br /> H/ ,•� $�7Testing Contractor or Company. BY Signature <br /> Serial of Thermal Certili ego.M <br /> Se L/ <br /> Senor <br /> i /1 //�y✓✓� Aderew <br /> Derth/ulon IS \•/ PNW27 <br />