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Y <br /> Data Hart for Tank S stem Tighass Test <br /> n a rs <br /> nip <br /> l ,v <br /> PLEASE PRINTAUH <br /> ' <br /> 1. OWNER Property ❑ <br /> ❑ 6 =twr <br /> '� SIY DR V 1 SC1cra�lto I representalive T . .,�� <br /> Tank(s) <br /> Ropnsantativs YsfetMons <br /> Name Address <br /> 2. OPERATOR Seven-Eleven (7-11 ) 4627 Davinei Road Stockton CA <br /> Name Address Taiephone <br /> 3. REASON FOR REGULATION GOVORUNGUND—MGMM S= 2MIS SITE-STANCES. <br /> TEST SUBCHAPTER 16 OF CHAPTER 3 TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE CODE, <br /> (Explain Fully) <br /> 4. WHO REQUESTED OWNER N Title Company or Affiliation Date <br /> TEST AND WHEN <br /> Telephone <br /> A� <br /> 5. WHO IS PAYINGOWNER Tine Telephone <br /> FOR i HIS TEST? Comoanv.Agency or Individual Person Authorizing <br /> Billing Address City State Zip <br /> Attention of: - Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVEDWEST <br /> 101000 REGULAR <br /> Location Cove Fills Vents Siphons Pumps <br /> 7. .INSTALLATION ONT NORTHDATA CONCRETE 4" Zee NO _ TURBINE <br /> BINE <br /> driveway. Concrete.Black Topa Size,TIWHI make,Drop Suction,Remote, <br /> Roar of station,etc. Eanh,ate. tutres.Remote Fills Size.Manaolded Which tanks? Make if known <br /> Is the water over the tank 7 <br /> 8. UNDERGROUND BEL0W TAMS <br /> WATER Depth to the Water table ❑ Yes ❑ No <br /> Tanks to be filled hr. Data Arranged by Name Telephone <br /> 9. FILL-UP <br /> ARRANGEMENTS 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 Company Name Telephone <br /> 10. CONTRACTOR, <br /> MEUTANICS. ---_-- —___ <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR 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 Re <br /> 12. TEST RESULTS as detailed on attached test charts with results as follOws: <br /> Tank identification Tight Leakage Indicated Date Tested <br /> TICCIT I NONE 18 1988 <br /> This is to oeanfy that these tank systems were tested an the dats(s)shown.Those indicated as"Tight'insist the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 328. <br /> JUNE 181 1988 Bill Campbell PETRO—COX�CI INC- <br /> Testing ontractor or Company. v: Signature <br /> 1819 D"° 414811816 271 OPPORTUNITY ST SUITE C SACRAMENTO CA 95838 <br /> Senal No.of Thermal Tochninans Address <br /> Sensor <br />