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CHAMPION PRECISION TANK TESTING: <br /> r DATA *ART FOR PETRO—TITS TANK S&EIS TIGHTNESS TEST: <br /> P.O. .BOX 13059 SACRAMENTO, CALIF. 95813-3059 <br /> PLEASE PRINT CALIF: 1-800-660-9443 NEV. 1-800-949-9443 (916) 927-1557 1 <br /> 1. OWNER proD«+y❑ <br /> Name Address Zip Representative Telephone <br /> Tanikls)❑ <br /> Name Address Zip Representative Telephone <br /> ,U 9 <br /> 2. OPERATOR Nat" Address zip <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBSTANCES <br /> TEST SUBCHAPTER 16 :CHAPTER 3 TITLE 23 OF CALIFORNIA ADMINISTRATIVE CODE: <br /> (Explain Fully) <br /> 4. WHO REQUESTED Title Company or Affiliation Date <br /> TEST AND WHEN ""nr <br /> Address Zip Tone <br /> lderift by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED J 1 4U <br /> Use additional lines <br /> for manitoidad tanks <br /> I' Cover ` Fills 1 <br /> Vents SiPtwnes 1pumps <br /> 6. INSTALLATION Sk;��Mvzitiif „ ll <br /> DATA �t�" l�'t� �if i��4�QM"► <br /> 7. UNDERGROUND is the water over the tank? <br /> WATER Depth to the water table from grade i E3Y°s "'o WELL POINT <br /> [ ] <br /> 8. FILL-UP TANK(S) TO BE FILLED: Qkl�w ! HR. DATE <br /> ARRANGEMENTS Extra product to'lop off-and nm tank tester. Now and who to provide? Consider NO Lead. <br /> TESTING CO. <br /> Terminal or other contact <br /> for notice or inquiry Company Narte Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> Involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials W others to be advised when testing is in progress or completed.Visitors or observers present dining test,etc. <br /> 11. TEST METHOD ❑ PETRO TITE # 2 ❑ SELF LEVELING STANDPIPE AND DTS. 2,000 <br /> Tats were made on the above tank systems in aceordtnce with test procedures prescribed for <br /> 11 a. TEST RESULTS as detailed on attached tat dwh with results a fokws: <br /> Tank identification Tight Nat Volume Change Per(lour Date Tested <br /> 12. SENSOR <br /> CERTIFICATION <br /> 1/23/92 Technicians <br /> Data t WILLIAM R. CAMPBELL CHAMPION PRECISION TANK TESTING <br /> 418 CA. 92-1324 1554 JULIESS9 ST. <br /> Serial No.of TPermat CerBlk:Nion 0 <br /> swam WILLIAM R. CAMPBELL SACRAMENTO, CALIF. 95813-3059 <br /> 2. <br /> C.arorcoorla NEV. UTT-1010 . <br />