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PLEASE PRINT <br />Q - i�_77S <br />"a Chart for Tank SystV Tightness Test. I <br />y - t6 <br />1. OWNER <br />Twit ft) <br />all» TNeplgrse <br />"ante Addrase ReprMentali» Telephone <br />2. OPERATOR <br />Nam. Ad&aaa TMephone <br />3. REASON FOR <br />TEST <br />IE.plam Fulty) <br />S I6 rL� <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Title Company t» Affiliation Date <br />"'n" �(c��28—t <br />Aooresa r.l.p.one <br />S. TANK INVOLVED <br />Use additional kc4a <br />$or.marrloloed tanks <br />lderltlty by Oir.ction c.p.oty 6-nd/Suppiw Grade Appro.. Aq. Sl"/Ftt_gtaa. <br />F <br />- <br />6. INSTALLATION <br />DATA�u��4� <br />Locatkxt weer Fills Vanfs Sronor pumps <br />t r <br />'on• R•. <br />Noon rnsWe61—Y. Concrete. Bia k Too. Sit.. TltefiM make. pop Sn•n'ot <br />Rear of station. etc E.%- etc lube.. Rartwt. Fllts S tre. Maniiolded WhrCh un1,37 M... d knorn <br />7. UNDERGROUND <br />WATER <br />to Vn —W oxer tn. tank, <br />Deptn to me w.tw tab'. <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be tilted 1LKL� n` I ' l� �L pate A+r.nq.d by <br />Name - T.t.pnon. <br />Extra product to lop otf- and run tank lett! ,o. and wno to pro/ dsT comidw NO L..a <br />TM nal w othw Conl.cl <br />for notice or irpuiry <br />Company Name T.t.pnone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contract(x <br />inwlvW <br />c—c;, <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />Aodil anal information on any Nemo .owe OfnclM. or olh_ b be adi.•d wh— t.elkV a in progre.e a completed. Vlsiton d ooeerv.n pr..•ru ounnq tau. we <br />11. TEST RESULTS <br />Tests were made on ttw above tank systefna In &0cW1dan0e wtth toot procedure" pr-cxibed for <br />as detalled on attached test darts with nattta as tosaws: <br />Tank IOantilion TpM L_kape Indlcat•d at. T..t.d <br />— <br />VI <br />12. SENSOR <br />CERTIFICATION <br />13. Tlda in to cwwy Ort two* tank ayatef le we, bated on Ow date(.) Owtwt. Tttoee k►dcowd as 1 meet the crM.r4a Netted by teas <br />Nadonat Rn Protecteon AseodaWn Pamp+ds( sza <br />T.cMticlan• c'cla ��.. <br />4 <br />to <br />' ( rT..tiqContrbor L <br />` <br />C.,ilnc.tlon . 5�• 1 \ `� ��j 1�I loo - 1 <br />Dec. <br />s.rtef No. a TMrmat <br />1 Ador— <br />z <br />C.ntttc.ttoo a <br />