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Data Lort for `dank System Tighlw ss. Test <br /> petroo Tite <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ /�� <br /> ❑ / Address Representative Telephone <br /> Tank(s) <br /> ame Address Representative Ttllephone <br /> 2. OPERATOR <br /> Name Address Teieohone <br /> 3. REASON FOR 7T 0 7 r <br /> TEST <br /> (Explain Fully) -- <br /> 4. WHO REQUESTED f '� <br /> TEST AND WHEN eme Title Company or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Agency or Individual Person Authorizing Title Telephone <br /> B ping Address City State zip <br /> Allen lion of. Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Appro Age St ee 'Fiberglass <br /> 6. TANK(S) INVOLVED _2 -ld r� ��-'r� <br /> L a on Cover Fills Vents Siphones f s <br /> 7. INSTALLATION C41 <br /> DATA (Sc <br /> North inside driveway, Concrete.Black Top, Size,Titefill make,Drop Suction,Remote, <br /> Rear of station,etc, Earth,etc. tubes,Remote f=ills Size,Manifolded Which hanks r Make if known <br /> 8, UNDERGROUND Is the water over the tank 2 <br /> WATER Depth to the Water table ❑ Yes V No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry - — <br /> Company Name Telephone <br /> 10. CONTRACTOR, — - <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials or others to be advised when testing is in progress of completed.Visitors or observers present <br /> during test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for PPtfO Tftf? <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank.Identification Tig t Leakage Indicated Date Tested <br /> �Q p <br /> This is to certify that these is Yate ere ties*on the date( sho n.�T1tOalhdifat d as"Ti t"meet the criteria established by <br /> 13. CERTIFICA1 the Natlonai Fir ect in iatio I 24. <br /> .-+RR -#NC. OF SACRAMENTO <br /> ..Date Testing ContraclfL. ".j3fX 19799 gnaw,e <br /> CAL11FAURNIA 95923 <br /> SerialNo of hermal Technicians AC- ! V/1 7 r <br /> Sensor <br />