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Data &rt for Tank System Tigh&ss Test <br /> CHAMPION'S PRECISION TANK TES'PIl\G <br /> PLEASE PRINT <br /> 1. OWNER Property DAY'S BAIT & TACKLE 5611 Waterloo RcJl�td, Stockton, California <br /> Name Address Representative Telephone <br /> Tank(s) o Attn: Dave <br /> Name Address Representar a Telephone <br /> 2. OPERATOR II ' 'i ©U I'ALO <br /> Name oo Address I Telephone <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS <br /> TEST SUBCHAP'T'ER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE COD <br /> (Explain Fully) <br /> 4. WHO REQUESTED OWNER <br /> TEST AND WHEN Name Tine Company of Affiliation Date <br /> Address Telephone 1) <br /> 5. WHO IS PAYING OWNER <br /> FOR THIS TEST? Company.Agency or Individual Person Authorizing Title Telephone <br /> Billing Address City State Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED i <br /> I <br /> Location Cover Fills �p ti .'f Vents Srphones Pumps <br /> 7. INSTALLATION �aT Ls;T- �t <br /> DATA viva <br /> C r? - top 44 �P7 ;j�; ° 4 �{- <br /> North inside driveway. Concrete.Black Too. Sire.Titefill make.Drop Suction.Remote. <br /> Rear of station,etc. Earth.etc. tubes.Remote Fills Sire,Mamfolded Which tanks? Make if known <br /> 8. UNDERGROUND Is the water over the tank 7 <br /> WATER Depth to the Water table Yes No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to­top off'and run TSTT. How and who to provide 7 Consider NO Lead. <br /> Terminal or other contact N O T APPLICABLE <br /> for notice or inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR. -L-E--- -- - <br /> MECHANICS, <br /> any other contractor <br /> involved -- --- ---- — — <br /> 11. OTHER — <br /> INFORMATION �T� .L �A$_ <br /> OR REMARKS <br /> Additional information on any items above.Officials or others to be advised when testing.s in progress or completed.Visitors or observers present <br /> during lest etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for R—eko TItp <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> _ Tank Identification Tight Leakage Indicated Date Tested <br /> t�. )v,./,Y(��or.r1 Irk°f'1'µ —� �+ !t •�l � � 6� <br /> P\ 1 r�"P e..'a.✓..��t'..... 13�ir1 � A �1 ; �f �i 4y <br /> 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 /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> 7-30-90 .' , �,.; r, e , CHAMPION'S PRECISION TANK TESTING <br /> Date Tessin Comractor or Com an ey &gnat ra <br /> 1451 OAKHURST 1�AY, SACRA, CA 9 822 <br /> Serial No of Thermal Technicians Address <br /> Snnw <br />