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4.1 A <br /> Data Clan for Tank System Tight, ;s Test <br /> 49 <br /> 3� <br /> PLEASE PRINT PETRO-CHECK INC. <br /> 1. OWNER property ❑ THE SOUTHLAND CORPORATION 4558 ROSEVILLE ROAD, NORTH HIGHLANDS, CA 95660 <br /> ❑ Name Address Representative Telephone <br /> Tanks) GRES CRAIG 916-149-9424 <br /> Name Address Rewasentabve Telephone <br /> 2. OPERATOR 7-11 #19976 1399 North Main Street, Manteca, CA 95336 (209) 239-2329 <br /> "''''• Dennis & �an Esenwein Address Telephone <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBSTANCES <br /> TEST SUBCHAPTER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE CODE <br /> (Explain Fully) <br /> 4. WHO REQUESTED OWNER <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING OWNER <br /> FOR THIS TEST? Company.Agency or Individual Person Authorising Title Telephone <br /> Billing Address City Suite Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED N S EAST 10,000 REGULAR <br /> N/S CENTER 10,000 UNLEADED <br /> N S WEST 6,000 PREM UNLEAD <br /> Location Cover Fills Vents Srphones Pumps <br /> 7. INSTALLATION LOT IN FRONT CONCRETE Ott 211 SUCTION <br /> DATA OF STORE <br /> North inside driveway. Concrete.Black Too, Size,Titefill make.Drop Suction.Remote, <br /> Rear of station.etc. Earth,etc. tubes.Remote Fills Size.Manifolded Which tanks? Make if known <br /> 8. UNDERGROUND Is the water over the tank 7 <br /> WATER Depth to the Water table ❑ Yes ❑ No <br /> ranks to be filled 8 pm hr. 6-14-89 Dare Arranged by Tom Bognar/David Newell <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> Involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS SAN JOAQUIN COUNTY <br /> Additional information on any items above.Officials or others to be advised when testing is in progress or completed.Visitors or observers present <br /> during test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for f0 jl� <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> REGULAR TIGHT +.017 _ 6_-_T4- <br /> UNLEADED TIGHT -.008 06-14-89 <br /> PREMIUM <br /> 6-1 - <br /> PREMIUM UNLEADED TIGHT -.021 06-14-89 <br /> This is to certify that these tank systems were tested on the dates)shown.Those Indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fin Protection Asociabon Pamphlet 329. <br /> 06-14-89 WILLIAM CAMPBELL PETRO-CHECK, INC. <br /> oat. <br /> Testing Contractor or ComDsny. By Signature <br /> 1819; 1972; 1854 414811816 2076 ACOMA STREET SACRAMENTO, CA 95815 <br /> Seryl No.of Themlei Technicians Address <br /> Sensor <br />