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bii <br /> tVjjbCALIF4V-J800- 3 SAC 0, CALIF. 95815 N <br />- EY 1 0-949-9 FAX- 916) 725-7345 <br /> OWNERS NAME NAME: km c �on,�< s T �.c� -,VzPH <br /> Property ADDRESS: n <br /> Jan CITY JW4FA-3,40*01'1 STATE: ZIP: 9 <br /> NAME OF LOCATION NAME: e�c e-n j6-5zd �"� <br /> -ADDRESS; 2 X <br /> CITY: rn,+,_ C+ ; <br /> RECORD OF NOTICE TO OWNER: A copy of all tests results have been filled with the proper <br /> FILING regulatory agency governing underground storage systems. ®- <br /> Y® N® If not filed, see ex laination below. C <br /> H <br /> Location of agency where filed. a <br /> REASON FOR TEST <br /> r � <br /> (explain fully) <br /> NOTICE: It is the owner's responsibility to contact the environmental health <br /> department of any failures within 24 hrs. of the final results. C; <br /> WHO REQUESTED NAME: PHONE: ( ) <br /> C+ <br /> TEST AND WHEN? <br /> ADDRESS: <br /> CITY: STATE: <br /> �x s <br /> ITEM OR SYSTEM Identif by Capacity Brand/Supplier Grade ifxknown Steel Fiberglass c�► <br /> TEST ® wn r -AA <br /> TANK ONLY <br /> WASTE O/L <br /> PRODUCT LINE <br /> VENT LINE ® vN <br /> VAPOR LINE cm <br /> ALL OF THE ABOVEC=3 <br /> a� <br /> FILL - UP Tanks to be filed. /6--00 for 6-z-7-gz Date �a <br /> ARRANGEMENTS <br /> Distributor <br /> Name <br /> Extra Product to 'top off' Y® N C <br /> �- <br /> OTHER OM <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any testing above. Official 's or others to be <br /> aevised when testing is in progress or compietea. vistors or observers D <br /> present during the test. c <br /> TEST RESULTS Tests were made ti the with®ve tank proceduressprescribedaccordance <br /> Results1th areHasner follo s• A s <br /> TANKS Check Leak Detection w p .v <br /> PRODUCT LINES an Tank Tight Lines Leak/Per Hr. Leak/Per Hr. Date es e <br /> Ind, Tank Detectedane <br /> VENT & VAPOR T7D ° <br /> LINES INCLUDED w'�n °�� N® Y O N ® -.002, <br /> Y ® N ®� c� ® O _ <br /> Y N Y ® N N <br /> CD N N= <br /> CERTIFICATION: as-iY®9 DATE: �-��- �z Ac- 4° 1q jc_e ,ctJ <br /> 5/d" 0007 <br />