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.� Data Art for Tank System Tightosst <br /> ORMI <br /> I 'S PRECISION <br /> PLEASE PRINT <br /> 1. OWNER Progeny ❑ Southland'Corpe (7-11) 4558 Roseville 43de.; North Highlands, Ca. '85660 <br /> Name Address Representative Telephone <br /> Tenk(s) ❑ Attn• Gres Craig <br /> Name Address Representative Telephone <br /> 1. OPERATOR <br /> Name Address - Telephone <br /> 3. REASON FOR REGULATION GOVLTNING UNDERGROUND <br /> TEST SUBCHAPTER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA AD1,9NISTRATIVE COD <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Tide company of Affiliation Data <br /> Address Telephone <br /> 5. WHO IS PAYING OWNER <br /> Company.Agency or Ino+viouai Person Autholiting True Telephone <br /> FOR THIS TEST? <br /> aillml;Address City State Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity 7tand/Suppiter Grade Approx.Age Steel/Fiberglass <br /> 8. TANK(S) INVOLVED 4 i <br /> p s �r <br /> ® I <br /> Location Cover Fills Vents Siphons m s <br /> 7. INSTALLATION <br /> DATA oFJ1 P <br /> North inside driveway. Concrete.Black Top. Size.Titafill make.Drop Suction.Remote. <br /> Rear of station,etc. Earth,etc. tubes.Remote Fills Sue.Mamfolded which tanks? Make if known <br /> 8. UNDERGROUND Is the water over the tank T <br /> WATER Depth to the water table ® Yes ® No <br /> Tanks to be filled hr. Date Arranged by_ <br /> g. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact NOT APPLICABLE <br /> for notice or inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS. NOT AFFLICA.BLE <br /> any other contractor <br /> involved <br /> 11. OTHER — <br /> INFORMATION NOT AfiffttCABthOR REMARKS <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 /> Tests were made on the above tank systems in accordance with test procedures prescribed for f0 TftP <br /> 11. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated I Date Tested <br /> • C4 <br /> tJosair I <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 324. <br /> 4-9-90 �- ION'S PRECISI ON TANK TESTING <br /> Otte - d TestCo , tSA C 11 <br /> - Spn <br /> 1451 OAL ST ta58 <br /> 22 <br /> Serial No of Thermal Technrc,ans Address <br /> C, , , <br />