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f ry <br /> Champion F.O. Box 13059 <br /> Sacramento, CA 95813.3059 <br /> Rreclsl*n Tank Testing CA 800-6640-9443 <br /> Ucan" No. 73848 <br /> NEV 800.949-9443 <br /> (916) 927.1557 <br /> Fax: (916) 927-7345 <br /> HORNER EZY-CHECK CERTIFICATION <br /> Owners Property Tanks(s) <br /> Company ' c �F , r;,w F.4,Y . , r Phone_( <br /> Address �D. ,< y� <br /> City. ..�,tj !Fr d✓ a s State !r 41- Zip <br /> Name& Location of Company+ <br /> Company %` 0r ��locrr'��� Phone_L <br /> Address-,; <br /> City S�r. .., ' State f"r+ Zip <br /> NOTICE To OWNER(S)l A COPY OF THIS TEST RESULT HAS BEEN FILED WITH THE PROPER REGULATORY AGENCY, <br /> WHICH IS REASON FOR TESTING <br /> 'NOTICE"IT IS THE RESPONS&UTY OF THE OWNER(S)TO CONTACT THE LOCAL ENv. HEALTH DEPT., IN <br /> HIS 1 HER AREA OF ANY TANK FAILURES WITH(24)HOURS. <br /> Who requested When? <br /> Identify by I.© Product Capacity Apx. Age Steel Fiberglass Brand/Supplier <br /> Tanks to be filled Date: 9 - o - 2,9 Time: / <br /> Distributor Extra Product to top off /© ' <br /> Comments <br /> REPRESENTAT;VE(S)OR ONNER(S)WILL BE NOTIFIED V HEN THE TE-57 HAS BEEN COMPLETED AND ONE OFFQAL MUST BE PRESENT DURING <br /> THE TESTING. ALL TESTS MADE ON THE TANK($)SYSTEMS ARE VALID THE HORNER-EZY CHEK LEAK DETECTION PROCEDURES. <br /> THrs CERTIFICATION SHOWS THE CRCTERIA ESTABLISHED BY THE HAT*T AL FIRE Assoc.{PHAMPLET'3291. / <br /> Test Results Include Tanks) E�" 6ne(s) C Vapor Recovery System event Une(s) L9' <br /> Tank Tight Tight Leak/Per Hr. Leak/Per Hr. Date Tested <br /> 1D# Tank Lanes Ind. Tank Detected Line <br /> 1 Y CSN ❑ Y N7 <br /> z Y 0/,N ❑ Y " ❑ os is a� - ✓/ ;''/ <br /> Y ❑ N ❑ Y ❑ N ❑ <br /> Y ❑ N ❑ Y ❑ N ❑ <br /> 4 <br /> Technician: � �� 1,6 2=j, Certification <br /> C--v -- <br />