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Data C _i for Tank System Tights Test t3 <br /> d9- FIR <br /> PLEASE PRINT PIEIR 3o-"O ECK I I� <br /> 1. OWNER Property ❑ =WSIDE PRODUCE 8960 WEST W GROVE ROAD, THORTON, CA 95686 <br /> Tank(i) ❑ Nemo Address MARY !LWOse6 <br /> 9"'DOUG 209—.7Z4p:,`i '+ 20 <br /> Name Address Representahve Telephone <br /> 2. OPERATOR SAME <br /> Name Addlsss Telephone <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND MIRAGE OF HAZARDOUS QE2 <br /> TEST SUBCHAPTER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE CODE <br /> (Explain Fully) <br /> OWNER <br /> 4. WHO REOUESTEO i� <br /> TEST AND WHEN Name Title [omWny Or ARdredon Date <br /> I!. <br /> Address TNePlIhons <br /> S. WHO IS PAYING OWNER .I! <br /> FOR THIS TEST? Company,Agency or Individual Person Authoi ing Tills Tsleohone <br /> ;� <br /> -Billing Address - CitY State zip <br /> .p. <br /> Attention at: 01041 160. Other Instructions - Ji <br /> Identify by Direction Capacity Brand/Supplier - Grade Approa.Aye Steel/Fitierglass <br /> 6. TANK(S) INVOLVED E/W NORTH 10,000 REGULAR <br /> E/W CENTER 10,000 DIESEL II <br /> E/W SOUTH 10,000 UNLEADED I� <br /> .I� <br /> Location Cover Fills Vents Siphorm Pumps <br /> 7. INSTALLATION IN FRONT CONCRETE 411 O 271 RED JACKET <br /> DATA OF STORE FWq 'TURBINE <br /> North inside driveway. Concrete.Black Too. Size.Titelill me e.Droo Suction;Remote, <br /> Near of station,etc. Earth.etc. tubes.Remot Fills Site.Manifolded Which tanks 1 Make if known <br /> B. UNDERGROUND Is the water over the tank t <br /> WATER Depth to the Water table ❑ Yes ❑ No i <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP tame Telephone <br /> ARRANGEMENTS Extra product to"top off'and run TSTT. How and who toprovide? Consider NO Lead. <br /> Terminal or other contact I� <br /> Tor notice or inquiry <br /> " COmpanY Name Telephoto <br /> .r <br /> 10. CONTRACTOR, <br /> any other contractor <br /> involVed , <br /> I� <br /> 11. OTHER <br /> INFORMATION it <br /> OR REMARKS SAN JOA UIN COUNTY ii <br /> Additional information on any items above.Officials or others tc be advised when testing is in progress or completed.Visitors or observers present <br /> during test etc. I� <br /> Tests were made on the above tank systems in accords a with test procedures prescribed for pP��O T1� II <br /> 12. TEST RESULTS' as detailed on attached test charts wi h rosuns as follows: <br /> i Tank.ldentdication _ Tight Leakage Indicated I Date Tested I� <br /> REG _ 6 <br /> DIESEL OT TIGHT ED__.__....___..— - 1- 9 -11 <br /> INLEMPT) TIGHT 006— - <br /> • r <br /> J , — — <br /> iM <br /> This is to certify that these tank systems were tested on dates)shown.Those indicated as"Tight"Inset the criteria estabffahed by <br /> 13. CERTIFICATION. the National tare Protection Asociation Pamphlet 329. • i <br /> WILLIAM CAMPBELL PETRO CHECK, INC. V <br /> Dau Testing Contractor or Company, By: S-9rubuto <br /> 1819; 1854; 1972 414811816 2076 NCOMA STREET SACRAMENTO CA 95815 !� <br /> Serial No of Thermal 7e0114c.ans Addisse <br /> SerlsOr li <br />