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i Data Chart for Tank System Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER Hppwly❑ ` I )r "r-1 I1 <br /> wms AOb.a Repmenl.h.e TeleOnone <br /> Torus❑ <br /> None, Addrw wprmr�reve Llepnone <br /> 2. OPERATOR NrM Aea� Te1epno„1 — <br /> ) 1 @1_11 l'RI)fE attfe r ) "J 712127 <br /> 3. REASON FOR - <br /> TEST Try 1, ): ! ?► ':i r i01 <br /> MaplMp Fully) <br /> 4. WHO REOUESTED Tad CornparAnaMel <br /> ksn o .-- <br /> TEST AND WHEN towns Taw <br /> AM. Telephone <br /> shortly by Dft=hon Cap.cny annd5 prier Draho Appro..Ape Staal/Fip.rplass <br /> 5. TANK INVOLVED I 1000 LLn 1.4061- _ <br /> t <br /> tee additional hnm <br /> for menifolded lanky ----- -- - <br /> L.110n Cover Fills Vents BlphoMe Ppmpa' <br /> 6. INSTALLATION 1?/4IL ov1 ) L <br /> DATA ) [fir l�`' efts I c E / ^� // ✓U C-HUY1 <br /> L <br /> North India aiwway. cancrMe.BIp4 Tp. sire.Tan”m.ke.DIM Sucflbn,Remold <br /> tutu of,I'll.,stn. E.M.etc tubes.Remote Fins slid,alanitolded Much banks? Mitxe If mown <br /> 7. UNDERGROUND Y IM wWer owe,the tank? <br /> WATER Depth to the Witter tame ❑Ye' ❑w <br /> 8. FILL-UP Tanks to be filed M. Dene Annged by <br /> Name Telephone <br /> ARRANGEMENTS Eats product W-top ofr and run tank toter. How and who to yrol Consider NO Lod. <br /> Terminal or other con.0 <br /> for nollce or Inquiry --- <br /> cdmmhny Name Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, —— - <br /> anyothereonlnetor <br /> pinioned ----- - <br /> 10. OTHER - - -- - - - - <br /> INFORMATION <br /> OR REMARKS <br /> Addltional ihlormMion oh itny items.ol Dumnh or omen to Oe ad.taed when testing h in progress or completedinshore or poser rom present during lest ee¢ <br /> Testa Nowa made on the above lank systems In accordance with last procedures prescribed lot <br /> 11. TEST RESULTS 'all detailed on attached test charts with results as loaows: <br /> Tank k1w0fintlon Tight Look...Ind..Ated Dale Tasted -_.--- <br /> 12. SENSOR 13 This is to certity that these tank eyalems were tested on the datap)shown.Tho"Indtdated O'TVhr meet the cltterts established by I <br /> CERTIFICATION National Pre Protxllon Maodatlon Pamphlet 328 <br /> FF <br /> T.chnlclaro / / r <br /> S' <br /> Data E8 fir T i 71T ( \s • �1 � <br /> Dat° 1. 1 ( /1I L 6cT(.l 01'b l � � I Ic ' � � -^ r_..._ ✓ <br /> y�7 y'9 A Toting OMtnmor W Comp.ny. BY Signature <br /> serol w of 11Thermal cadinullon a �'L, fit��I�� / /'1 �1,�� I }�/ 1 ,1 l'�/' ) (�n_ C�y��_�- <br /> Sanaor _S/ L-1 <br /> AMrms <br /> 2 <br />