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d <br /> Data art for Tank System i ss Test <br /> PLEASE PRINT <br /> PETRO-COCK�WC- <br /> 1. OWNER Property ❑ THE SOUTHLAND CORPORATION 4558 ROSEVILLE ROAD, NORTH HIGHLANDS, CA 95660 <br /> ❑ Name Address GREReCprResAenItaGtive Telephone <br /> Tanks) — q—qd2A <br /> Name Address Representative Telephone <br /> 2OPERATOR 7-11 #20632 4627 Davinci Drive, Stockton, CA 95207 209 952-3543 <br /> Name Mary Lindsgy Address yessawom <br /> 3. REASON FOR REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBSTANCES <br /> TEST SUBCHAPTER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA AEMINTSTRATIVE CODE <br /> (Explain Fully) <br /> 4. WHO REQUESTED OWNER <br /> TEST AND WHEN Name Tide Company or Affiliation Data <br /> Address Tetephon <br /> 5. WHO IS PAYING OWNER <br /> FOR THIS TEST? Company.Agency or Individual Person Authorizing Title Telephone <br /> Billing Address Citv State Lip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Stool/Fiberglailig <br /> 6. TANK(S) INVOLVED N/S EAST 10,000 UNLEADED <br /> N/S CENTER 10,000 PREM UNLEAD <br /> N/S SOUTH 10,000 REGULAR <br /> Location Cover His Vents Siphons Pumps <br /> 7. INSTALLATION FRONT OF CONCRETE 411 211 RED JACKET <br /> DATA SPORE TURBINE <br /> North inside driveway. Concrete.Stack Top. Size.Ttafip make.Drop Suct m Remote. <br /> Rear of station.etc. Earth.SM. tubo.Remote Figs Sue.Manifolded Which tanks? Make it known <br /> 8. UNDERGROUND is the water over the tank <br /> WATER Depth to the Water table ❑ Yes ❑ No <br /> Tanks to be filled 8 PM hr. 5-30-89 Date Arranged by ToM I=ar or CITGO, David Newell <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. Now and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS SAN JOA UIN COUNTY <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 accordetirce,wm test procedures proscribed for <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: WMA- <br /> Tank Identification Tight Leakage Indicated I Date Tested <br /> UNLEA DED TIGHT -.009 _05-30-89 _ <br /> TIGHT -.031 05-30-89 <br /> REGULAR TIGHT -.018 - 05-30-89 <br /> This is to certify tlkkt these tank systems were tested on the s)shown.Those huficated as"Tight'mat the critertal estobfished by <br /> 13. CERTIFICATION! the mational Fire ftotection Asocishon Pamphlet-3n <br /> -- WILLIAM CAMPBELL PETRO-CHECK, INC. , <br /> Date Toting Con' <br /> rector or Company. Sy: Stgnatiare <br /> 1819; 1972; 1854 414811816 2076 ACOMA STREETSACRANENTO, CA 95815 <br /> Sana)No of Thermy Technicians Address <br /> S«,$« <br />