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Lata Chart for Tank Sys, m Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER progeny❑ Nam. -- J,.: rer�E SZL- >� -- <br /> bnxbl El wM TNeohore <br /> Name Addreer Reymamet'. Telephone <br /> 2. OPERATOR Name Aad.ere Tio"hl <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REOUESTED <br /> TEST AND WHEN Name Title Company or A%motkan Dote <br /> Add,. Telephone <br /> Identity by Direction Capacity ennd.5uppller Grade Apple..Ape Svil/F1Wrglaee <br /> 5. TANK INVOLVED <br /> (be additional Ince <br /> for manifoldad tanks <br /> Location Cover Fill, Venn Sipronea pompe <br /> 6. INSTALLATION <br /> DATA `- <br /> North inside driveway. Concrete.Black Top. Size•Tllefill make.Drop Suellen.Ramose. <br /> Rear of station,Nc. EarM,erg. tuber•Remote Fills Sze,% riftdad "Loh t.nk.? Make%known <br /> 7. UNDERGROUND I,the wWWover the tenki <br /> WATER Depth to the water table ❑vea ❑Ne <br /> B. FILL-UP Tank,w W filled hr. Data Ananpao by <br /> Name Telephone <br /> ARRANGEMENTS Extra product to top off'and run tank tatter. How and who to proridei Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry, <br /> Camprry Name Telep%oM <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any What contractor <br /> Involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional Information on any Rama above.Official,or When to W advised when tatting N In progress or oomplated-Manor,or pesernhe present during Leal.We. <br /> Temple wen made on the above tank systems In accordance whh test procedures pnaddbed for <br /> 11. TEST RESULTS as detailed on attached test charts with results a follows: <br /> Tank Identification Tght Lae4ga Indicated Data Tested <br /> zve �Vjc 4`/ 14`11 sly <br /> i <br /> 12. SENSOR 13.Two is to cMtiT that these tank syat.mai wan fated on tM datela)shown.Those Indcated as-nghr meet tM criteria alabibtwd by the <br /> CERTIFICATION National F"e Protection A"°Waeon PamphM 32n <br /> Tachmcki e &4,04 <br /> /� <br /> &4,0 • e �Gb►'r LSl•G.�iLt��. <br /> Telling conn/Wlw or Y ey/�fulnNwa <br /> 9wiel Hp <br /> Senor of T%NmN Gm%CeliMa r. .l� rxk 1I1 C� <br /> rY <br /> Aad ea <br /> cMi%Cation 0 pNggyT <br />