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• CHAMPION PRECISION TANWESTING: <br /> DATA CHART FOR PETRO—TITS TANK SYSTEM TIGHTNESS TEST: <br /> t P.O. _BOX 13059 SACRAMENTO, CALIF. 95813-3059 <br /> m <br /> EASE PRINT CALIF. 1-800-660-9443 NEV. 1-800-949-9443 (916) 927-1557 <br /> 1. OWNER Property❑ <br /> Name Address Zip Representative Telephone <br /> Tank Is)❑ <br /> Name Address Zip Representative Telephone <br /> 2. OPERATOR <br /> Name Address Zip Telep O <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 REOUESTED <br /> TEST AND WHEN ""Te Title Company or Affiliation Date <br /> Address Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade ADprox.Age Steel/Fiberglass <br /> i. TANK INVOLVED V)— \ `T = <br /> ! n L \� iiUse additional lines <br /> for manifolded tanks - <br /> Location Cover Fills Vents Siphones Pumps <br /> 3. INSTALLATION <br /> DATA <br /> 7. UNDERGROUND !�^+��(���(t (^� +��..f��f Is the water over the tank? <br /> WATER Depth to the water table from grade�`^`✓� `^ ` `� ❑yes ❑No WELL POINT <br /> 3. FILL-UP TANK(S) TO BE FILLED: 0_ cQQ HR. DATE <br /> ARRANGEMENTS Extra product to"top off'and run tank tester. How and who to provide? Consider NO.Lead. <br /> TESTING CO. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> I. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> Involved <br /> is <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials or others to be advised when testing is in progress or completed.Visitors or observers present during test.etc. <br /> 11. TEST METHOD © PETRO TITE # 2 1 0 SELF LEVELING STANDPIPE AND DTS. 2 , 000 <br /> Teats were made on the above lank systems In accordance with test procedures prescribed for <br /> 11 a. TEST RESULTS as detailed on attached test charts with results as.follows: <br /> Tank Identification Tight Net Volume Change Per Hour Date Tested <br /> C!� % 14 <br /> jS5 03—I r <br /> 12. SENSOR <br /> CERTIFICATION <br /> 1/23/92 Technicians <br /> Date , WILLIAM R. CAMPBELL CHAMPION PRECISION TANK TESTING <br /> 418 CA. 92-1324 1554 JULIESSE ST. <br /> Serial No.of Thermal Certification# <br /> Sensor <br /> z WILLIAM R. CAMPBELL SACRAME 0, CALIF. 95813-3059 <br /> Codification# NEV. UTT-1010 <br />