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MAY 2 s 189-- Data Chart for Tank System Tightness Test <br /> ENVIRONMENTAL HEALTH <br /> !'ERMfT; <br /> 'LEASE PRINT <br /> r <br /> 1. OWNER Property❑ Re rowmsli a Telephone <br /> T.nklsl <br /> ❑ %t% �-/ y <br /> 1r am. �- <br /> Telephone <br /> Name <br /> 2. OPERATOR Address zip Telephone <br /> Name <br /> 3. REASON FOR apt 11 <br /> TEST <br /> B.ple n Fully) <br /> 4. WHO REQUESTEDN.ne , Company or AXllislion Del. <br /> TEST AND WHEN <br /> Addrese Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Aye Sleel/FiIoulleas <br /> 5. TANK INVOLVED h S <br /> Use additional Iles <br /> for mandoided tanks <br /> Loultem pp Cover Fills vent y/ Siphones Pu^JDti� ,Mm <br /> 6. INSTALLATION 1o)4-r k <br /> DATA 4,}-N r-te L a r <br /> 4 V e P <br /> Suction, known <br /> North inside drlvaway, Concrete,Black Top, S'ue, al l.,make.Drop Which tanks? Make it known <br /> Rear of stellae,etc. Earth,etc. IUBes.Remote Filla Sire,ManilPlded <br /> s the water o.er the Lanka <br /> 7. UNDERGROUND <br /> WATER Depth to the water ladle from grade <br /> 0©r' e aY Pc�dCpG�C / ❑Yes �Nn <br /> /�/�� -C) aV G <br /> Tanks to be lilled(L?m hr. 0 Z Data Arranged oy Nie Telephone <br /> 7 17 <br /> 8. FILL-UP <br /> ARRANGEMENTS Extrs product,o'Yop oly'and run le k tester. Now and who to pruldr Co^alder NO Lee'. <br /> Twminel or other contact <br /> for notice or notary Name TelePnone <br /> Gampeny <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any Other contractor <br /> involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additbnal inbrmetion on��any^Items above.officials or others to W edviaed when testing is In progress or completed.Visitors or ohsarvers present during lest.eta. <br /> 11. TEST METHOD yq PETRO TITEif— ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Tate were made on the above tank systems in accordance wlth test procedures Prescribed for <br /> 11a. TEST RESULTS as detailed on attached test charts with results as follows: <br /> i, hl NM Vormea Change Par Hour Date Tasted <br /> Tank Identification g ---- //� <br /> ii:iff <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION a <br /> CERTIFICATION <br /> Dale ,. I.. - Testing ConlrePtor or Core"'Y. signatureori �� �G� 9liedal No.of lurmNG � T ` <br /> Sp.Of Addr� <br /> PNN2a <br /> Certification 0 <br />