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I <br />PLEASE PRINT <br />1. OWNER Property <br />Tank(s) El <br />2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />5. WHO IS PAYING <br />FOR THIS TEST? <br />DCort for ata i <br />QUICK STOP MARKETS, INC. PO BOX 5745, FREMONT, CA 94537 <br />Name Address Representative Teleph 'R <br />JACK GRIFFITH 415-657—��00 <br />Name Address Representative Telephone <br />QUICK STOP MARKETS, INC. 1721 SOUTH EE, LODI, CA 415-657-8500 <br />Name Address Telephone <br />REGULATION GOVERNING UNDERGROUND STORAGE OF HAZARDOUS SUBS'T'ANCES <br />SUBCHAPTER 16 OF CHAPTER 3 OF TITLE 23 OF THE CALIFORNIA ADMINISTRATIVE COI: <br />OWNER <br />Name Title Companv or Affiliation Date <br />Address Telephone <br />OWNER <br />Company. Agency or Individual Person Authorizing Title Telephone <br />Billing Address City State Zip <br />Attention of: Ober No. Other Instructions <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />6. TANK(S) INVOLVED E/W NORTH <br />10,000 <br />water <br />REGULAR <br />NEW <br />FIBERGLASS <br />10,000 <br />WATER <br />UNLEADED <br />NEW <br />FIBERGLASS <br />E/W CENTER <br />E/W SOUTH <br />81000 <br />WATER <br />PREM UNLEAD <br />NEW <br />FIBERGLASS <br />11. <br />INFORMATION <br />OR REMARKS <br />Location <br />Cover <br />Fills <br />Vents <br />Siphons <br />Pumps <br />7. INSTALLATION SOUTH SIDE <br />EXPOSED <br />411 <br />21r <br />TOKHEIM <br />DATA OF STORE <br />TURBINES <br />North inside driveway. <br />Rear of station, etc. <br />Concrete, Black Top, <br />Earth, etc. <br />Size, Titefill make, Drop <br />tubes. Remote Fills <br />Size, Manifolded <br />Which tanks? <br />Suction, Remote. <br />Make if known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table NJA MMIE MAT I, TANKS" 1:1 Yes El No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by _. <br />Name Telephone <br />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 <br />Company Name Telephone <br />10. <br />CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />_ — <br />involved <br />OTHER <br />TANK TESTS CONDUCTED USING WATER. LINE TESTS CONDUCTED USING WATER. <br />11. <br />INFORMATION <br />OR REMARKS <br />SAN JOAQUIN COUNTY. <br />12. <br />TEST RESULTS <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 Petro Thea <br />as detailed on attached test charts with results as follows: °'• ' <br />Tank Identification Tight Leakage Indicated Date Tested <br />REGULAR TIGHT —.00803-02-89 <br />-- <br />UNLEADED TIGHT —.005 — 03-02-89 <br />PREMIUM UNLEADED TIGHT —.008 03-02-89 <br />I <br />13. CERTIFICATION <br />03-02-89 <br />Data <br />1819; 1854; 1972 <br />Serial No. of Thermal <br />Sensor <br />This is to certify that these tank systems were tested on the dates) shown. Triose indicated as "Tight' meet the criteria established by <br />the National Fire Protection Asociation Pamphlet 329. <br />BILL CAMPBELL/CLINT DENMAN PETRO—CHECK, INC. C, <br />414811816 / 414813888 271 OPPORTUN `S"Y':`�```":"�, 'SAC} CA 58; <br />. _ _.. <br />Technicians Address <br />