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PLEASE PRINT <br />ta t ' 11%]" k System Tightness Test <br />ENVIRONMENTAL HEALTH <br />PERMIT / SERVICES <br />1. OWNER Property ❑f <br />�}— <br />Address Re tint ve �;' <br />Telephone <br />Name Address Representative <br />Telephone <br />2. OPERATOR <br />Name Address <br />Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />7 <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Nemo• Title Company or Affiliation <br />Date <br />Address <br />Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for mandolded tanks <br />Identity by Direction <br />Capacity <br />Brend/Supplfer <br />`` <br />Grade pprox. Age <br />Stsel/Fiberglass <br />�J <br />6. INSTALLATION <br />DATA <br />Location <br />(_ (- r' .7 <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />[ fa��rl r."'76 <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />Size, Titistiji.Make, Drop <br />tubs to Fills <br />Vents Siphones <br />( r <br />Size, Manifoided Which tanks? <br />Pumps <br />Suction, Remote. <br />Make if known <br />7. UNDERGROUND <br />WATER <br />(� <br />Depth to the Water table" /� <br />15 the water overt <br />F� El Yea <br />lank, <br />No <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filledL-�^ �) hr. t2 �4 Date Arranged by Name <br />Extra product to "lop off" and run tank tester. Now and who to provide? Consider NO Lead. <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />10. 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 during test, ac. <br />11. TEST RESULTS <br />Tests were mads on the above tank systems In accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />'2 <br />12. SENSOR 13. TMs isto carttty that thew tank systwm was' I.d on the date(s) shown. Those Indicated as 'nphr mast the crhw% sistabilshed by the <br />CERTIFICATION 0"'I Prolschort Association Pamphlet 3ft <br />Teohn. V I <br />Dots%� <br />Testing Contractor or Company. By: Slgnatun <br />Serial No. of ThermalCeAtlication r l ` / / `� �' <br />Sensor <br />Address <br />2 <br />Certification 0 PNS? <br />