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Data Cha for Tank System TightnE Test <br /> CHAMPION'S PRIDciSiON TAS TEST11113 APR 2 3 fir7 I <br /> PLEASE PRINT AL H�_ I <br /> 1. OWNER Prop.rty ❑ --Southland Corp. (7-11) 4558 Roseville iRd. , #C North,Highlan s, <br /> Name Alto, is ReDresentatir• Telephone <br /> Tank(s) ❑ rat <br /> P. <br /> Name Address ReDnrentabw Teleoh one <br /> 2. OPERATOR 1T <br /> Name Address Telephone <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE I <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 Tme Comoanv of Affiliation Date <br /> Adorers Telephone <br /> 5. WHO IS PAYING OWNER <br /> Company.Agency or Ind—dual Perron Authorrr,np Title Telephone <br /> FOR THIS TEST? <br /> Billing Address City State Ap <br /> Attention of. Order No Other Instructions , <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED - E-661- 1 A 000 ziax luz.. <br /> V)Ib- tri4me, t o,coo <br /> rill S-U.\.ft7 b f o00 QC•J�N i V!1(e <br /> CLcrcation Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION l"�� •�'�;' <br /> DATA b F <br /> e�erpQF �V1�,+'�.r'fr. L•� k ,., ,, a SJ..�� <br /> North inside driveway. Concrete.Black Top. Sre.Tilebll .it.,Drop Suction.Remote, <br /> Rear of station.etc. Earth.etc. tubes.Remote Fills Sire.Mendolded Which tanks' Make d known <br /> 8. UNDERGROUND Is the water over the tank 7 <br /> WATER Depth to the Water table ❑ Yes ❑ No <br /> Tanks to be filled hr. Date Aaanged by <br /> 9. Fill-UP Nome Telephone <br /> ARRANGEMENTS Extra product to"top off'and run TSTT. How and who to provide r Consider NO Lead <br /> Terminal of other contact N O T APPLICABLE <br /> for notice or inquiry <br /> COMDany Name Telephone <br /> 10. CONTRACTOR, — — <br /> MECHANICS, <br /> any other contractor <br /> involved '-- -- <br /> 11. OTHER - ------- <br /> INFORMATION NOT - _ <br /> OR REMARKS _ <br /> Additional information on any Mems above Officials or others to be advised when testing is in progress or completed.Visitors or observer;present <br /> during test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for PPtirO TILP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated I Date Tested <br /> `izr 1 ;4. <br /> Y1 L r--d10 ISS-0 fS —,old { - I) - 4 Di <br /> This is to certify that these tank systems were tested on the das)teshown.Those indicated as"Tiflht"meet the criteria eatablislted by <br /> 13. CERTIFICATION the is <br /> Fire Protection Aaociation Pamphlet 329. <br /> 4-11-90 CHAMPION'S PRECISION TANK TESTING <br /> Dau � i Testin Contoctoi or Com an Br Sign t�e � — <br /> 0) Z 3Z 1451 OAKHURST FAY, SASI' CA �3�822 <br /> Sent No of Thermal Technicians — Address -- <br /> Se..ery <br />