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L/dld lr. it IUI 1 d11K JyJlClll 1 IlJllll 'IjJ 1 CJl <br /> petro Tate <br /> PLEASE PRINT <br /> TANK <br /> 1. OWNER Property Arco _P.O. Box 5817 San Mateo, CaP,i.6. 94402 Ron Mite,6 1-800-421-7457 <br /> Ns n• <br /> Tank([) El <br /> Addre.a --..—_______- R•prq•nunvs T•lapnone <br /> Addrets _— <br /> T•NOnon• <br /> 2. OPERATOR ARCO #595, 5100 N.- _H wy. 99/Hammer Ln. , Stockton, CA <br /> Name - ---- - Addy... _ - _ -- -- --- - --- - Tdepnone <br /> 3. REASON FOR To check on ti.ghtnuz <br /> TEST - - - - <br /> (Explain Fully) - <br /> 4. WHO REQUESTED Ron M-i,eu Arco <br /> TEST AND WHEN "an`�,0, Box 5811 San Mateo. Ca 6oAnia 94402 `O1"pe 14 Affiliation eQflje" <br /> Addreu TN•OnOne <br /> 5. WHO IS PAYING Anco Ron Mitu came <br /> FOR THIS TEST? f"n'•'n"53 " us' San Mateo, MWv Ma 94402 T"" T'lephoo. <br /> awing Add,.. City SYN Zip <br /> Attention of: Omer No. Other lnsnuctions <br /> -Ran- Ai.FOA <br /> 6. TANK(S) INVOLVED <br /> Identify by Direction Capacity Brand/Supplier Credit Approa.Ape Steel/Fiberglass <br /> oeo Z llU«gAM- ) (<4 S <br /> (id 11– <br /> 3 -�SY.coo U <br /> Location Cover Fills Vertts Siphons Pumps <br /> 1. INSTALLATIONf:�tS', ��► [ .ft, <br /> DATA Ln u R <br /> North Inside drlvswdy. Concrete.slack Top. Sue,TINIw snake.Droo Suction,Rsynote. <br /> Real or station,etc. Earth.sec. rue...Ranote Fiat Slre,Man"olded Which units T Mak•"known <br /> 8. UNDERGROUND is this wait«over the tank r <br /> WATER Depth to the water table- <br /> Yea � No <br /> Tanks to be filMd C1, r3 <br /> 9. FILL-UP Dau Arranged by K'�,n- !'N y 21-?u S 7 <br /> Name <br /> ARRANGEMENTS Extra Product to-top off"and run TSTT. How and who to provide 7 Consider NO Lied. T•laphon• <br /> Terminal or other contact <br /> for notice or imuiry <br /> ComOsny Nome TMephone <br /> 10. CONTRACTOR, <br /> MECHANICS. <br /> any other contractor <br /> irnolwd <br /> 11. OTHER t f,t1iJ rg153 rc <br /> A <br /> INFORMATION N/` 4 LA CL- - <br /> OR REMARKS <br /> Additional W rmation on any item.above.OHieiak a otMrs to be advised when testing is in progress or completed.Visitors or observers prsent <br /> during test etc. <br /> Tests wet meds on the above tank sys$sms M acoordance with last Procedures prsscrlbsd for p ►p�S <br /> 12. TEST RESULTS as detialied on attached lest charts wfth mautts se touows: 'w�r�fstR <br /> Tank kl.ntilieation Tight Looks"Indicated Dau Tested <br /> xt <br /> Y1 0 <br /> 1),r /li Poop <br /> All At �,�;, <br /> Theis is to�that M"'e tank sy"ones wets$"tad on the date(*)shown.Those k"Wcated a 'Tight msec the ClWarta"tablished by <br /> 13. CERTIFICATION <br /> the Matlonal Fks Protection Asoclation Pamphlet 329. / <br /> /-Dot.� AL3cZ_ LCI / ,� <br /> .y <br /> Testing Conlisclor or Company. Illy Signature <br /> 414810519 P. O. Box 1220, Tulare, CA 39275 <br /> S.rtal No.or TT•chnicuns <br /> h.nnN <br /> hyo, Address <br />