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`I <br /> Data Chart for Tank System Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER Pdp.ty C/TSS OFS7L�7tkJ /S/loS 5. < /Ncy� 95 3V& SUZYf�CIJl35 yl'//a <br /> Tank(s) Name Address Zip Repreaintatiw Telephone <br /> Name Addres. Zip Rapraxntatiw Talaphon, <br /> 2. OPERATOR E/VG AJ,i /o <br /> Name Add. Zip TNaphone <br /> 3. REASON FOR Nl/ <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTEDtin�i� <br /> TEST AND WHEN company or Affiliation Dat. <br /> .� .v -1/ a_//00 <br /> Add. Zip TSMphge <br /> Identity M Dani capacity Brand1i.p Iier Grade Apym..Ape Sten/Fiheret. <br /> 5. TANK INVOLVED W <br /> Jae sdanan.l nbw <br /> for manllddW tanks <br /> L tion Coker Fill. Vents &Phorea Pumps <br /> 6. INSTALLATION <br /> DATA SIDE or <br /> 'euitDf"14 N ry��1� Su�noA1 <br /> North Inde ddvekiay. Concrete.Black Top. Sets.Tlteell make.Drop Suction.Remote, <br /> Mar 0 naawn•Mc liardt.Na Militia.Remote FIN We Mani olded Whits tanks? Make d or. <br /> 7. UNDERGROUND Is the watero.•aTr qtM tank? <br /> WATER Deptewthawaurem <br /> elelrpgrad. 4w'C Ely. L71Nd <br /> Tanks to a Blled/1� W. +V�'90 Dna Anneved MC•LJ. heOSE.L/?fiNL ck 142-//IJV <br /> 8. FILL-UP Name Tnepn.n. <br /> ARRANGEMENTS ear.prodwd a om Ield ren Wk ttaw.nd kind to wo.ia.? Cdnaifer No I...d. <br /> 7.I aat«.;;;nd 1 712 Of c <br /> rminn dr othe ron a C rtf <br /> for o� xaln� SE�e s� cAr6s vd� ira> <br /> Tor rONCe r kW iry SR <br /> canPam Neme Water. <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any otter contractor <br /> involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any nems abi Officials or nhere to oe advised when hi b in progress or complaed.Vizdora of observers Warrant future beet,etc. <br /> 11. TEST METHOD � PETRO TITE ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Tests were matte on the above tank systems in accordance with test procedures prescribed for <br /> 11a. TEST RESULTS es detailed on anaChod had charts with results m toddlers: <br /> Tank IdentiTiubion TipM leakage Indicated / Data d <br /> Teste <br /> 0� 5 T <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION f 0:36 <br /> CERTIFICATION 5 yy-gµs3 <br /> L1/'1-ye,—,17 TTechnicians /. <br /> Date rC.L./• "(/..7�N�U//(.0 1� (:,7V4K5 '(�-r:*J C. (it/• Tr,a_1 C�-- <br /> 1-55711 Testur,Connector or Company. By Slynetum <br /> Swire No of Senor Thermal CMINutlons S'/y�i�/0�/�/ /ydJ s 5. moi./.'�u/ _'T <br /> /. �s [� <br /> 2. C-4 t7c °r /� •/a� Add. - <br /> Gentncanon e <br /> PNfieP] <br />