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1. OWNER `•ft,,,❑ <br />Tank fa) ❑ J <br />Ultramar `Inc.:` P.O. <br />Box 4-6 Hanford, CA' 93232 <br />-:-,Julies. Caldwel <br />Name Adds. Rpresenatlw <br />209)T -T"-878 <br />Name -- , . _ _.. Address ... Rprsssrnfatiw <br />TN phone - . •- <br />:: 2.OPERATOR :.,_ . - <br />Ti <br />T6 <br />2 0 9 <br />Name Aearees —TNphone <br />& REASON FOR:- <br />(Epialn Fully) ..,r <br />u ermits <br />4. WHO REQUESTED- <br />= TEST AND WHEN <br />- <br />Norma.. ari Tyle Company or Affiliation <br />z .. .-. <br />Date <br />Address <br />Telephone <br />�, . .. <br />5:- TANK INVOLVED-, <br />addiftloind <br />IN atatlbldedde anku tm. <br />Wentlfy by Diravoon " <br />Capacity .;. <br />ewndBpplar• : <br />fired- <br />Approx. Age <br />Stsel/Flberglass <br />12,000 <br />513-1 <br />Premium <br />1966 <br />12,000 <br />513-2 <br />Unleaded <br />1966 <br />12,000 <br />513-3 <br />Re ular <br />1966 <br />6. INSTALLATION <br />DATA <br />Location. 1 <br />E, pF. <br />Wol "a drlvevray, <br />- Rear of alatiorb NG <br />flown <br />rate, 1solt Top. <br />atG 1 <br />Fab <br />stte. Titetllt make. Drop <br />tubes, Remote Film <br />vents <br />sloe. Manifolds <br />Siphons <br />Which tank.? <br />Pump$ <br />wAyAvt <br />STP <br />suction. Remote. <br />Make a known <br />7. UNDERGROUND <br />WATER <br />Depth to the water aa. d ' GJ t// �bi.� <br />w the water over the wk? <br />0Y. 19N. <br />6. FILL -UP <br />ARRANGEMENTS <br />Tanks to a lisle - hr. Date Arrarped w Now <br />Extra Product lo " op off" and run tank tater. How and who lo provide? Consider NO Lead. <br />TNpherna <br />Terminal or Otho contact ' <br />for notice or kWulry <br />Company Nan <br />Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />Additional Informatlorn on any hem. Neve. officials or others to be advmsd when testhg Y in progress or complete. Visitors or observers present during test etc. <br />11. TEST RESULTS 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 Wsntlacetion Tight Laakaps indicated Data Tested <br />513-2 unleaded oyzs 9J i <br />513-3 regular itsyJVA <br />,J <br />12. SENSOR 13. This Is to certify that these tank systems were tested on the date(s) shown. Those Indicated as "Tight" meet the criteria established by <br />CERTIFICATION the National Fire Protection Association Pamphlet 329. <br />it is the responsibility of the owner and/or operator N this system to immediately advise state and local authorities of any <br />Implied hazard and the possibility of any reportable pollution to the environment as a result N the Indicated failure of this <br />Dale } system. Heath Consultants Incorporated and/or SACRAMENTO EQUIPMENT MAINTENANCE COMPANY, INC. does not " <br />4 assume any responsibility or liability for any loss of product to the environment. <br />Seryl No. of Thermal (Yrtlkits.Sensor <br />Cd LJA Taft Owner/ Daycwvncatim a Operor <br />i <br />.t•ir <br />+:..x":!a'a$1a Smarr AAt <br />