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Champion P.O. Box 13059 <br /> Precision Tank Testing <br /> Sacramento. CA 95813-3059 License No. 7354$ CA 800-660-9443 <br /> NEV 800-949-9443 <br /> (916) 927-1557 <br /> Fax: (916) 927-7345 <br /> HORNER EZY-CHECK CERTIFICATION <br /> Property <br /> Owner_ 104y.140K7-H ,cAa&C 14 <br /> Address • 13_ y Al, MADiSttk <br /> Tank Address : w� - <br /> *Notice to owner(s)* A copy of this test result has been filed with the proper regulatory <br /> agency. It is the responsibility of the owner(s) to contact the local Env. Health Dept. in <br /> his or her area of any tank failure within (24) hours of testing. <br /> Tank; Product Capacity Apx . Age Steel Fiberglass Supplier <br /> Tank(s ) were filled on : Distributor : <br /> Date Time <br /> Extra product to top off:,No[ ] Yes [ ' - Gallons <br /> Comments - <br /> TEST RESULTS INCLUDE <br /> Tank(s ) Product Line ( s ) r/ Vapor Recovery System Vent Line(s ) <br /> Tank Tight Tight Leak indicated Leak indicated Date of <br /> ID7 Tank(s) Line( ? ) <br /> per hr. ( tank) per hr. ( line ) testing <br /> Yes[ No[ ]Yes [ ]No[ ] ,G, OfJd' <br /> Yes[ ]No[ ]Yes[ ]No[ ] <br /> .:—Yes [ ]No[ ]Yes[ ]No[ ] <br /> Yes [ ]No[ ]Yes[ ]No[ ] <br /> --Yes[ )No[ ]Yes[ ]No[ ] <br /> —�Yes[ ]No[ ]Yes[ ]No[ ] <br /> Technician: License T: -/5� <br /> �9 Date : 1=-2-o c{ S' <br />