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sesse- <br /> Sacramento Equipment Mai nance Company Inc 5 E M Cls <br /> 2533 Connie Drive / Calif.Contr. License N5023A7 <br /> Sacramento, CA 95815 Wo�, �jt�j��-j <br /> `LEAS 9RINT Data Chart for Tank System Tightness Test Station 5�(O1 <br /> PLEASE PRINT <br /> 1. OWNER Property❑ <br /> Tw*(s)❑ Name Addrer URepne.ntatiw T1111450— <br /> Name - Address Reprftmtatlw Telephone <br /> 2 OPERATOR _. 2 2 <br /> Name Address' Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) .,- <br /> 4. WHO REQUESTED <br /> .TEST AND WHEN Nen" This company or Affiliation tete <br /> Address Telphons <br /> Identity by Direction Cap" Brand/Supplier Grade - Approx.A" Steal/Fiberglass <br /> 5. TANK INVOLVED <br /> tlee additional antes m✓ <br /> for manifoided tanks 0,1560 — <br /> r <br /> Location cover Fills Vents siphpres Pumps //'' <br /> 6 DATA INSTALLATION 56 14 % // Recd f <br /> Or- �a f <br /> North Inside driveway. Concrete Zack Top. six•.TitaHll make.Drop section.Remote, <br /> Rear Of atatlon,Na ,Nc. tubas.Remote F4 Bt m.Manitoided Which tanks? Maks It known <br /> 7. UNDERGROUND r ae water Over the tank? <br /> WATER Depth to the Water ewe ❑Y. ❑No <br /> B. FILL-UP Tonka ro a Next h.. Dat. Arranged W None Telephone <br /> ARRANGEMENTS Extra"dud to lop otr and run tank Wer. Now and who to provlds?Conti..NO Lead. <br /> Terminal or other oontW <br /> for notice or k+rrrlry <br /> Company <br /> 9. CONTRACTOR, 1 L <br /> MECHANICS, <br /> any otter contractor - `i_..e:•i !r�� -I�. <br /> involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional Information on any Hams above.OHklals or others to be advised when Mginp Is to proprio or oompM.d.Visitors or observers present during taat,etc. <br /> 11. TEST RESULTS Tests we-re made on the above tank systems In accordance with test procedures prescribed for <br /> as detailed on attached test charts with results as follows: <br /> Tank Idenafbatbn Tight Leakage k dlc&W Date Tested <br /> 6 I. C / — / — r/' <br /> G 14es -� ! - 1 -a <br /> 12. SENSOR 13.This Is to certify that these tank systems were tested on the date(s)shown.Those Indicated as"Tight'meet the criteria established by <br /> CERTIFICATION the National Fire Protection Association Pamphlet 329. <br /> Tedr110iatM It is the responsibility of the owner and/or operator of this system to immediately advise state and local authorities of any <br /> hazard and the possibility of any reportable pollution to the environment as a result of the indicated failure of this <br /> Date i. <br /> 1. 52�4� ystem.Heath Consultants Incorporated and/or SACRAMENTO EQUIPMENT MAINTENANCE COMPANY,INC.does not <br /> /0 —//./z_// 7 y� assume any responsibility or liability for any loss of product to the environment. <br /> serial No.of Thermal CNaffcaaon a <br /> Sinton <br /> C <br /> cerNflation. //YR'/�3 i r Tank Owner/Operator X Date <br /> 101 <br />