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1 <br />PLEASE PRINT <br />Champion S <br />n <br />Precision Tank Testing <br />License No. 73848 Data Chart for Tank System Tightness Test <br />1. OWNER P.open,❑ <br />Tank (s) ❑ <br />FLAME LIQUOR 1301 WEST KETTLEMAN LANE 1 CID t, r.AI rF_ (209)314_���� <br />Representative <br />Name Address Zip e 7alepnon <br />Name Address Zip Representative Telephone <br />2. OPERATOR <br />SAME AS ABOVE! <br />Name Address Zip Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />REGULATIONS GOVERNING UNDERGROUND STORAGE OF HAZARDWS SUB-S-M.CES-SUBSTANCE <br />SUBCHAPTER 16 OF CHAPTER 3 TITLE 23 OF CALIFORNIA ADMINISTRATIVE CODE. <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Arte rine Company or Affiliation Date <br />Address Zip Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identity by Direction <br />Capacity Brand/Supplier Grade Approx. Age Steel/Fiberglass <br />-- <br />.^✓! /+✓ <br />C+�/ <br />4/t5 <br />re <br />Al? 00 P <br />6. INSTALLATION <br />Location / <br />S'QG��lt L✓eS� <br />f/Ir�ry�f0+ <br />-ton- <br />rth inside driveway, <br />Rear of station, etc. <br />Cover Fills Vents Siphons Pumps <br />o� �4/ �l Ar0r SJ�tlf� <br />G crime G 2 y10 stp <br />Concrete, Black Top, Size. Titelill make. Drop Suction, Remote. <br />Earth, etc. tubes. Remote Fills Size. Manifolded Which tanks) Make if known <br />7. UNDERGROUND <br />WATER <br />1 ,� Is the water over the tank? <br />Depth to the water table from grade i »S7� • " IJ Yes ® No <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name Telephone <br />Extra product to 'lop off' and run tank tester. How and who to provide? Consider NO Lead. <br />TESTING COMPANY <br />Terminal or other contact <br />for inquiry <br />notice or <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />' <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />SELF LEVELING STANDPIPE AND DIS 2,000 <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 <br />9 PETRO TITE 5- <br />❑ PETRO COMP <br />❑ QUICK CHECK 2000 <br />11 a. TEST RESULTS <br />Tests were made on the above tank systems In accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight Net Volume Change Per Hour Date Tested <br />>` 1r -0/2 G. r ' Z <br />t l -eo � a � 'r g l r/ Z <br />p u flya -�z <br />12. SENSOR <br />CERTIFICATION <br />13. CONTRACTOR CERTIFICATIVZ ,q7, CHAMPIONS PRECISION TANK TESTING <br />P.O. BOX 13059 <br />Technicians SACRAMENTO, CALIF. 95813 <br />0at <br />Testing Contractor or Company. By: Signatuve <br />Certification e U/pFl-B Q3r32_ <br />Date <br />Serial No. of Thermal <br />stCtG 13--114 (916)927-1557 CALIF. A°i=s800-660-9443 <br />NEV. 1-800-949-9443 <br />1"� <br />