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Data Chart for Tank system Tightness Test <br /> PLEASE PFflttilY.- 2 1 a c7E] <br /> t NW60M E41T,A UH EA AddressTelephone <br /> Representative <br /> FERMIT/.$E CES nho Telephone <br /> Name <br /> dress Represent ve p <br /> z�C f <br /> 2. OPERATOR Name� Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED All <br /> Company� <br /> TEST AND WHEN Name <br /> Tltl® cr Date <br /> Telephone <br /> Address <br /> Brand/Supplier pplier Grade Approx.Age n eI Fi/be/rg'"lI /J <br /> Ida by Direction Capacity r(,5f �'r <br /> 5. TANK INVOLVED i .> A�oa L/�-�t � Gh� <br /> Use additional lines - <br /> for manifolded tanks <br /> cation Cover Fills Vents !� Siphones f Pe <br /> 6. INSTALLATION <br /> DATA <br /> IyAlc?� �"�' T <br /> North inside driveway. Concrete,Black Top. Size,Tile make.Drop <br /> Suction,Remote, <br /> Rear of station,et¢ Earth,etc. tubes,Remote Fills Size,Mardolded Which tanks? Make If known <br /> Is the water over the tank? <br /> 7. UNDERGROUND ❑Yes ONo <br /> WATER Depth to the water table <br /> Tanks to be filled hr. Data Arranged by Name Telephone <br /> B. FILL-UP <br /> ARRANGEMENTS Extra product to'lop off`and run tank tester. How and who to provide? Consider NO Lead. <br /> Terminal or othercontact <br /> for notice or inquiry 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 on any items abpva,Officials or others to be advised when testing is In progress or completed.Visitors or observers present during test,etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on attached test chats with results as follows; <br /> Ti bt Leakage Indicated Date Tested <br /> Tank ldentitication g ` / <br /> 12. SENSOR 13.This is to certity that these k systems were tested on the date(s)sh Those Indicated as"nghr meet the criteria established by the <br /> CERTIFICATION National Pre Pro"? atlon pomp et 329 <br /> ans <br /> eating Contract mpany. By: Signature <br /> (� <br /> Se ial.No,of Thermal Certification N n }� <br /> Sensor - ids V� AMENTD <br /> ' x`95 <br /> PN6827 <br /> Certification M <br /> � 4LIFORNIA 9.5823 <br />