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t, Data rt for Tank System Ti-j"ness Test <br /> LEASE PRINT <br /> 1. OWNER F.ap..ro❑ <br /> Name Address, Z.D Awwasntar.w Telephone <br /> Tank la)C] e <br /> Me— Addreu Z.D Rewasentahw T onone <br /> i r <br /> 2. OPERATOR Name Add, Zip 9 Taewwne <br /> 3. REASON FOR <br /> TEST 16 OF CHAPTER 3 TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE CODE <br /> (Explain Fully) <br /> 4. WHO REOUESTED <br /> TEST AND WHEN `'"'"' T"0' Compeer w Affiliation Dae <br /> Addras &D Telephone <br /> Idatfilyr by(Direction Capaoty erandrsarppker ada Approx.Age SteetlFibargtaas <br /> S. TANK INVOLVED } t <br /> es, <br /> L►.sawiond cert« <br /> for manefolded tanka <br /> tAwionr Cover Filts, Van�t Siphons Pwhps <br /> 6. INSTALLATION m IIa a le=e (//re's/►� (L) I <br /> DATA I Y1 <br /> insideCIM66, IN <br /> e <br /> driveway. Concrete,stack Yob. Size.Titefin ro <br /> make.DMO Suction.Remota. <br /> Rea ON station,ac. Earth.air. tubes.Remote Pots Size.Mandfoided Which tanks? Make it kndem <br /> 7. UNDERGROUND t^may tIs me wa1ef deeQP the twk? <br /> WATER Depth to the water table from grade 1"� l L' -m In kA Dyes ❑No <br /> 8. FILL-UP Tams ss De fdW hr. °'^'e Ogle Arranged by <br /> Nance Telephone <br /> ARRANGEMENTS Extra jimpuct to lop Otrtank tester. t4ow and who to pro.460 Consider NO Lead. <br /> rurt <br /> e <br /> Saminal or other contact <br /> Aar notice or le0uiry Company Nome Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS. <br /> any Other Contractor <br /> involved <br /> 10. OTHER ;EI E I EVFI TN(; STANnPTPF An njS 20nD <br /> INFORMATION <br /> OR REMARKS <br /> Addeonst information on any items above.Ot"C'als Or-Mn to be sovised when testing is in progress or Compered.Ysifon w observers present Outing test.CIC. <br /> 11. TEST METHOD PETRO TITS ❑ PETRO COMP ❑ OUICK CHECK 2000 <br /> Tests were made on the above tank systems In accordance with test procedures prescribed for <br /> 11 a. TEST RESULTS as detatted on anached test charts with resufts as,foftows: <br /> Tam tdentitieation Tight PM Volume Change Per Mo.a Oat.Tested <br /> tLAr- — ' 616 r <br /> � s <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> CERTIFICATION <br /> is 201_�- ATectvucierr <br /> Dolov t CHAMPION'S PRECISION TANK TES G4_t_'�e_� <br /> Tsatetg r--,--Company. By: synatun <br /> "�o'*^« �� P.O. BOX 13059 SACRAMENTO, CA. 95813-3059 <br /> s-»a <br /> Ao-w <br /> 1-800-660-9443 <br /> PN"27 <br />