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Data Chaothvr Tank System Tightne#Test <br />C MMICV IS RMISICK OW Mr <br />PLEASE PRINT -- <br />1. OWNER Prop.rty - MAenly Station -& Mini Mart 14)45 .Magni _St. , Escalon, Car <br />AOdrMs IlapaaMtehra <br />Tank (s) <br />Frank Miner11a 219-8387621 <br />Nama <br />Addvaa. AarerasarrtahT• <br />6, •r , �, � ;� -� r , t ,r f ,, , ; i j _ ti . ,^r.ti d s 1 , ' l'; <br />2. OPERATOR <br />NameAddr•st <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />''rIC # • 319 • '! � ��•ae • e�: a•.• j► `Ili.i:►M <br />_ u . Tsar.■ a.E .• 11Y:: IU •46 <br />Name <br />5. WHO IS RAYING <br />OWNER <br />FOR THIS TEST? <br />ComoenT. AgencT or rAGrvadYN <br />Pw►rpw <br />Billing l.dGrKa <br />, <br />An•ntron 01 <br />Identify by Direction,, <br />Capacity <br />via .. i <br />6. TANK(S) INVOLVED <br />• <br />(}" <br />7. INSTALLATION <br />DATA <br />6. UNDERGROUND <br />WATER <br />9. FILL -UP <br />ARRANGEMENTS <br />10. CONTRACTOR. <br />MECHANICS, <br />any othw Contractor <br />involved <br />11. OTHER <br />INFORMATION <br />OR REMARKS <br />12. TEST RESULTS <br />Addr••il <br />Panon AutAonring <br />City <br />Old., No. Pfrnr <br />6rand/Suppbw Grade <br />'. t- I �1 <br />Do wrtayredn <br />rrstnx"ns <br />Approa. Age Sive{/Frbrerglata <br />Additional inlormatron on any 11tms a00ve 411,Cials or others to be advised when testing -S rn progress or Comprerao..ra.rws__- <br />during test41C <br />Taoswe made on It" above tank systems in aCCordance weds teat procedures preocnb id for P-0141 t] 1 e <br />as detailed on atlached test charts with results a$ follows: <br />Tans Identijicairon Tight Leakage Indicated Date Tested <br />This is to C*" that the" lank systema wen treated On the dste(s) shown. Those indkxled as "Tight'- meet the crime ns 06t0bb0hed by <br />13. CERTIFICATION the kabortal Fin projection Asocistlon Pamphlet 3". <br />CHAMPION'S PR£CIS1413 TANK TESTING <br />— T•snn Conrr.c+or a� Cor* 8 SW • <br />1451 OAKHLTRST 4uAY, SACRA'!C, C'A��822 <br />Address <br />Seryl No of ThamaV TKnnc....s <br />Cover <br />Fills Yens' <br />S'�1OM' <br />Pw►rpw <br />Courson <br />, <br />i- <br />via .. i <br />• <br />(}" <br />�• <br />r <br />Norm rnfida <br />Corierine. alae• TOO. <br />make <br />Sr i•.Wsi'IM�MiewonFrna G S ra. M.rrlDld•d <br />WMCA tams I <br />S,acaon. Itamota. <br />Maki A kr n <br />Haar of snudn. Inc <br />Earn. etc. <br />Ia the water Dvw Vee jank ? <br />El Tres No <br />Dopth to the W~ table <br />Tanks to be filled hr. <br />date Arranged by <br />Narn• Tekw* a <br />Erna product to "top off" and run TSTT. <br />How and who to provide ? Consrdw N4 Lead. <br />Terminal or other Contact N O T APPLICABLE <br />for notice or Mtqurry - <br />Name taNprwA• <br />tDTpaAr <br />NV <br />Additional inlormatron on any 11tms a00ve 411,Cials or others to be advised when testing -S rn progress or Comprerao..ra.rws__- <br />during test41C <br />Taoswe made on It" above tank systems in aCCordance weds teat procedures preocnb id for P-0141 t] 1 e <br />as detailed on atlached test charts with results a$ follows: <br />Tans Identijicairon Tight Leakage Indicated Date Tested <br />This is to C*" that the" lank systema wen treated On the dste(s) shown. Those indkxled as "Tight'- meet the crime ns 06t0bb0hed by <br />13. CERTIFICATION the kabortal Fin projection Asocistlon Pamphlet 3". <br />CHAMPION'S PR£CIS1413 TANK TESTING <br />— T•snn Conrr.c+or a� Cor* 8 SW • <br />1451 OAKHLTRST 4uAY, SACRA'!C, C'A��822 <br />Address <br />Seryl No of ThamaV TKnnc....s <br />