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edS14 ank 'Testing <br /> Licens N®. 73848 <br /> DATA 'CHART FOR TANK SYSTEM TIGHTNESS TEST <br /> PLEASE PRINT <br /> 1. OWNER ProgenyEl <br /> Tank is)❑ Name Adore" Zip Representative Telephone <br /> Name Address ..Zip Representative Telephone. <br /> 2. OPERATOR ORLANDO' S BAIT AND TACKLE 5611 WATERLOO ROAD STOCKTON, CA F. <br /> Name Address Zip Telephone <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBNT—ANCES <br /> TEST SUBCHAPTER 16 CHAPTER 3 TITLE 23 OF CALIFORNIA <br /> (Explain Fully) CODE <br /> 4. WHO REOUESTED <br /> TEST AND WHEN Name Title Company or Affiliation pate <br /> Address Zip Telephone <br /> MentifeJav Direction Caoacity Brand/Supplier Grade Approx.Ace Steel/Fioar lass <br /> 5. TANK INVOLVED EAST JqEST B ,QOQ PREMIUM STEEL <br /> lks additional NDIESELEAST WEST 10 ,QQQ STEEL <br /> for <br /> -- <br /> for manifolded tanks EAST WEST 12 ,000 UNLEADED STEEL <br /> Location cover Fills Vents Siphons Pumps <br /> 6. INSTALLATION NORTH CONCRETE 4" WITH 2" WITH RED <br /> DATA <br /> OF OVERFILL VENT JACKET <br /> STORE PROTECTIOD CAPS TURBINE <br /> 7. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the water table from grade BELOW TANKS / DOMESTIC WELL ❑ya% �� <br /> 8. FILL-UP Tanks to be filled 0700 hr. 11/05/9?Date Arranged by <br /> Name Telephone <br /> ARRANGEMENTS Extra product to <br /> gip.off"and run tank tester. How and who to provide. Consider NO Lead. <br /> TESTING CO. <br /> Terminal or othi r contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> arty other contractor <br /> invoked <br /> 10. OTHER SELF LEVELING STANDPIPE AND DTS. 2,000 <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.Mellon.of observers present during test.etc. <br /> 11. TEST METHOD 91 PETRO TITE # 2 ❑ PETRO COMP ❑ QUICK CHECK$Q00 <br /> Tags were made on arc above tank systems In accordance with test procedures prescribed for •� <br /> 11 a. TEST RESULTS sis'detalled on attadled test dnsrts with results as . <br /> Tank Identification Tight Nsl Volume Charge Per NOW Date Tested <br /> PREMIUM PASS _ 009 11/05/92 <br /> DIESEL PASS +.002 11/05/92 <br /> UNLEADED PASS +.025 11/05/92 <br /> I" SENSOR <br /> CERTIFICATION <br /> Date` 23te We CAMPBELL C ION'S PRECISON T TESTING <br /> ,,. /. <br /> 418' ry/faa92-1324 P.O. BOX 13059 SACRAMENTO CALIF. <br /> Sabal No.OI Thermal - <br /> Certification <br /> - Sensor <br /> 2 - <br /> 916-927-1557 1-800-660-9443 CALIF. <br /> SACRAMENTO 1-800-949-9443 NEV. <br /> fertificetwn. <br />