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Data Chart for Tank System Tightness Test i <br /> PLEASE PRINT <br /> 1. OWNER PraperlyRl ! rLtl95-Jr b�l'JP / .AW %4h LIotLJ�s 9 <br /> Tank(sl ,N� e T" Adareas Zlp Raproumatiu Tela on <br /> 12 <br /> Nam Address Zip Representative Telephone <br /> 2. OPERATOR Sow" t <br /> Name Address Zip Telephaw <br /> 3. REASON FOR it J2 Id N Ot S <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED - -e 1' y' <br /> TEST AND WHEN Name 1P h �a g6 compamyorAnalaU°" .24)1 r Dan <br /> Address Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approa Age Steel/fiberglass <br /> 5. TANK INVOLVED Sat&A TanK to&B0 ? S <br /> ©E-3i— led <br /> — ._. <br /> Lsa additional linea <br /> for manlfolded tanks - -- — ---- -- -- - <br /> Location Cover Fills Vents Siphones Pumps <br /> 6. INSTALLATION 1%ry,BF T-ded� m�P <br /> tont; 'l" � R42t <br /> DATA Z'o-10(IrIts C'l j 104 1-2m <br /> mn Av'itt <br /> North inside driveway, Concrete.Black Top. Size.Titefill make.Drop Suction,Remote, <br /> near pl station,etc F.erlh,etc lubes,Remote Fats Size,Mandolded Which tanks? Make d known <br /> 7. UNDERGROUND Is the lwwater over the tank? <br /> WATER Depth to the water table from grade L l Yes No <br /> 8. FILL-UP Tanks to be fhledlVD—hr e Arranged by ✓ty Nhe 0 Name Telephone <br /> ralapnone <br /> ARRANGEMENTS Extra product to to self'and run tank tester'How and who m provma? Consider NO Lead <br /> a_ � __5 bio,P © k e� <br /> Terminal or other contact <br /> for notice or Inquiry_— <br /> Company Name Telephone <br /> 9. CONTRACTOR, ------ <br /> MECHANICS, ?�'"�� ' ¢v� <br /> any other contractor I -is ■i V I Y <br /> involved am W I—"I W cm 2111111111, <br /> 10. OTHER <br /> A 2 4 1990 <br /> - - <br /> INFORMATION €NVIRONMENTAL HEALTH <br /> OR REMARKS <br /> Additional information on any items above Officials or omen to be advised when testing is in progress or I drums haat en, <br /> 11. TEST METHOD ❑ PETRO TITE = ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Tests were mode on the above lank systems In accordance with teat procedures prescribed for <br /> Ila. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Idenitticanon Tight Net Volume Change Par Hour Date Tested <br /> 6KiR� _ _'c�TLrn 3— e­i— — <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> OE // AFFORDA - TE$1" <br /> �R.TI ON Technicians ` � 8I2 C c t !-T <br /> D lA44 „u GALT.OA.A583' <br /> 6-31 1// Testing Conth obr or Company 9y Sign sswe <br /> Serol o.Nof Thermal Cemflcetlon a A11HB'!�-8"�7 <br /> Sensor 1 ,r <br /> D�aL� �{— 11 N l� Address <br /> Certification 0 MW27 <br />