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'lata Chart for Tank Syst Tifitness Test <br /> v 2 ;3 1988 <br /> ,PLEASE PRINT .:'ENTAL WEALTH <br /> 1. OWNER Pro{rarry L1 _� _ _ <br /> F-71 <br /> Na ddresse�e Telephone <br /> N me Address Rep osentative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Till@ Company or Affiliation <br /> — Date <br /> v—. - - Address Telephone <br /> Identify by Dir tion Capacity arMd/Su plier Grade Approx, Sleel/Fiberglass <br /> 5. TANK INVOLVED ' re [) © / f �. <br /> Use additional lines <br /> for manilolded tanks ------- — —_- <br /> /09.1 1.n Cover t=ills Vents Slphones Pumps <br /> 6. INSTALLATION (" P <br /> DATA <br /> /&AADt) <br /> North inside drlveway. Concrete.Black Top, Size,Tilefill make,Drop Suction,Remote. <br /> Rear of station etc. Earth,etc tubes.Ramble fills Size,Manifolded Which tams? Make If known <br /> 7. UNDERGROUND is the water ocer the(ank9 <br /> WATER Depth 10 the Water table <br /> - — Li Y. KNo <br /> �. FILL-UP Tanks to he idled_- hr _Date Arranged by <br /> Name Telephone <br /> ARRANGEMENTS Extra product to"top off'and run lank tester. How and who to provide? Consider NO Lead, <br /> Term Ina]or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 9. CONTRACTOR, — <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 10. OTHER —_--- — — <br /> INFORMATION <br /> OR REMARKS <br /> Additional information oh any items above Officials or others to be advised when leafing is in progress or completed.Visitors or observant present during test,etc <br /> Teets we made on dw above tank systems In aaeordence with test procedures prewdbed for <br /> 11. TEST RESULTS les detailed on elteel»d tset charts wtlh results as looms: <br /> Tank loentification Tight leakage Indicated Date Te ed <br /> 12. SENSOR 13. � ��tsr*sy PO IIIA r on the dele(e) meet the a#te fw*40 tehed by the <br /> CERTIFICATION 329 <br /> T no <br /> t. <br /> n9 eng Contr panty. By: Signrture <br /> al of Thermal Certincatlon■ __ rt.� 100 TRIANGLE <br /> R'�# r INC. <br /> Sensor 1�nl `G <br /> BOX 9795 Address <br /> SACRAMENTO, CALIFORNIA <br /> CsrtlflG■Gon a 95$� <br /> PN6827 <br />