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• t Data art for Tank System Tigoess Test 5AwjU,+o (fi ;,j <br />petro Tite <br />PLEASE PRINT TANK TESTER <br />1. <br />OWNER Property <br />Chevron USA, Inc., 2 Annabel Lane, suite 200 <br />Tank(s) �X <br />ban Ramon, CA 94583 Address Tony A?'aU 05v ( 415) 8 V1050 0 0 <br />Name Address Representative Telephone <br />2. <br />OPERATOR <br />/ d 6,74 ANW—ri <br />Name Address Telephone <br />3. <br />REASON FOR <br />State requirement <br />TEST <br />-- <br />(Explain Fully) <br />—'--"---- <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />A.J. ( Tony) Arado Engineer Chevron USA 7/21/86 <br />`2men <br />Anabe 1 Lane , suite Ti0 0 . , San Ramon, °'"` '11or Affiliation ( 415) 838-P51000 <br />Address Telephone <br />5. <br />WHO IS PAYING <br />Chevron USA, Inc. A.J. (Tony) Arado Engineer (415) 838-5000 <br />FOR THIS TEST? <br />`2mDKhfta1�e °ivir°ane, suite P tSO°"°"Z"'San Ramon, CA 10.4583 Telephone <br />Billing Address City State Zip <br />Attention ol:---------------------Order No. Other Instructions — ---- <br />6. <br />TANK(S) INVOLVED1QWQ <br />Identify by Direction <br />tne r <br />Capacity <br />---����o <br />Brand/Supplier <br />&evroo_ <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />1. <br />INSTALLATION <br />DATA <br />Location <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />Concrete, Black Top, <br />Estill, etc. <br />Fills <br />Size, Titelill make, Drop <br />tubes. Remote Fills <br />Vents <br />Size, Manifolded <br />Siphones <br />Which tanks? <br />Pumps <br />Suction, Remote, <br />Make if known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table Yes No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name Telephone <br />Extra product to "top off' and run TSTT. How and who to provide? Consider NO Lead. <br />Terminal or other contact <br />for notice or inquiry <br />Company me Telephone <br />10. <br />CONTRACTOR, <br />O.H. Materials Corp. nCr d h �uur, <br />MECHANICS, <br />_ <br />3900 Industrial Blvd. ''� <br />any other contractor <br />_ <br />W. Sacramento, CA 95691 <br />involved <br />11. <br />OTHER <br />INFORMATION <br />INFORMATION <br />FERwftsavleES <br />_. _ <br />-------------- - . _ __ __.- _ ____ _._. _ _ ------- <br />' <br />— - <br />OR REMARKS <br />- -- <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present <br />during test etc. <br />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for petro nhe <br />as detailed on attached test charts with results as follows: rAN.IFS71R <br />Tank Identification Tight Leakage Indicated Date Tested <br />fi•0L <br />2 6 <br />13. CERTIF CATION <br />g Z� 64 <br />This is to certify that these tank systems were tested on the date(s) shown. Those indicated as "Tight' meet t e criteria established b <br />the National Fire Protection Asociation Pamphlet 329. /'` <br />I O rt.t e n �� if at4rl � l o <br />Testing Contractor or Company.­df3W OE <br />—Sign <br />Date C <br />Serial No. of T ermal 7echnicians Address <br />Sensor jA✓t bj_ <br />