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' <br />TANK CERT TION & Horner <br />�.Y ��- <br />LOCATION DATA CHART leak detector <br />OWNER'S Property <br />NAME Tank(s) <br />3r -P � CO <br />emorione <br />I+, Jf'6�� PR-'SpCr—1 R� .17AA-c4a. .f�2• . _ C'.,'ld� c, T c J <br />gsc Zo <br />Aaareus CW Zip <br />NAME OF <br />LOCATION <br />-t /L C Ue 2 V3- U7g8 <br />Nurse Tetewwe <br />L O 3 CC L4 AJ •r ti C. L I, . L v 0 %cr C r-1 At o4 c r «." <br />Aoo"= City Zw Cpunty <br />NOTICE TO OWNER A copy of all test results have been filed with the proper regulatory agency governing underground <br />storage systems. Yes ❑ No CfYIf not filed. see explanation below: <br />RECORD OF <br />FILING <br />Location of agency where filed: <br />REASON FOR <br />TEST <br />NOTICE: It is the owner's res por>sibi6ty to contact the environmental health department of any faikras within 24 his. of the rascrlLs <br />(Explain FtAy) <br />given to the owner. <br />WHO REQUESTED <br />TEST AND WHEN? <br />Name) Date <br />- O • r'.3 j U it - 322 1 —1 7 <br />Adores etevnwte <br />ITEM OR SYSTEM TESTED <br />toernhy tly Direction Capacity Bramisuppior Grade Aoorox. Aga Slee i hbeglus <br />of owner IDr (it known) <br />? t nc t P� C3PRODUCT <br />TANK ONLY @",/ <br />UNE D' <br />VENT UNE 9-11 <br />�' Ou % - a' ❑ <br />30oO ? /0 -yo 7 ❑ <br />VAPOR UNE 0 <br />ALL OF THE ABOVE 0 <br />3 000 O u t3� ❑ <br />FILL -UP <br />Tarty to berated r• �'1 . M. O — J " ! nails <br />ARRANGEMENTS <br />_ <br />EDisrtbubr <br />S�F.-S� tion,. <br />caa prodtta to'top or/YFS I HO <br />OTHER <br />INFORMATION <br />OR REMARKS <br />Additional information on any items scow. Officials or others to be advised wnen lestawj is in progress or completed. Visitors or observers present during <br />test etc. <br />Tests were made on the above tank systems in accordance with Homer EZY Check Leak Detection test <br />procedures prescribed for as detailed on attached test charts with results as follows: <br />TEST RESULTS <br />TANKS <br />Tank Identification a Lines Only Tight Leakeage Indicated Date Tested <br />1 Yes No ❑ - OO G 3 <br />PRODUCT LINES <br />"L Yes C}/>�lo ❑ ^, Q 5' 0 <br />3 Yes No ❑ �p , <br />/ <br />-Vaper & Vent Yes 8 <br />Lines Included No 13V <br />Yes No C3 -t opo / <br />Yes ❑ No ❑ <br />CERTIFICATION <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 the <br />(National Fire Protection Association Pamphlet 329.) CALIFORNIA UNDERGROUND STORAGE TANK REGULATIONS <br />Q _6 5 <br />` 7 <br />ARTICLE 4 SECTION 2643 ( ) (f <br />DENNIS E GOOOAN -- �• <br />Date <br />Technician <br />