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Ata Chart for Tank Syst0 Tightness Test <br />PLEASE PRINT <br />1. OWNER Property ❑ <br />Tank(s) ElAName <br />A Z `�% �6 �ti IPiF+T%' Qxi FF55 <br />I Address Zip Representative Telephone <br />� �90 <br />Name Address Zip Representative Telephone <br />2. OPERATOR <br />Name Address Zip Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />C O' -^^'4^r ��'L S <br />Name Title Company or Affiliation Date <br />Address Zip Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identity by Direction <br />t o��tw Eton <br />Capacity <br />lcO <br />Brand/Supplier <br />Q C-� <br />Grade <br />Approx. Age <br />SteeliFiberglass <br />13 �. <br />U-0 1A 6 po'n 0 i4 <br />jc <br />Fken�T <br />i <br />S <br />6. INSTALLATION <br />DATA <br />Location <br />VASA <br />e (----- <br />J1..-0, W to <br />North inside driveway, <br />Rear of station. etc. <br />Cover <br />(.s�CR-C-t't� <br />Concrete. Black Top, <br />Earth, etc. <br />Fills <br />4 ++ <br />Size. Titefill make. Drop <br />tubes, Remote Fills <br />Vents <br />� <br />Size. Manifolded <br />Siphons <br />Z - (ooOJ <br />V �t �-A'Dt3� <br />Which tanks? <br />Pumps <br />l�'L OTS <br />Suction, Remote. <br />Make if known <br />7. UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the water table from grade ❑ yes © No <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled ' `30 hr. r Date Arranged by i J Zi 1_� !"'fly <br />Name Telephone <br />Extra product to 'lop off' and run tank tester. How and who to provide? Consider NO Lead. <br />Terminal or other contact <br />for notice or inquiry <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />�Tm tZt <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />' <br />Z- %j,4rA,,ja Tb b<<--if[-vz <br />3) �,Lcn,a,f7 Lti�� �,u crn, tP- i L^ Are, Z�Z'Z <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present during test. etc <br />11. TEST METHOD <br />® PETRO TITE <br />❑ PETRO COMP <br />❑ QUICK CHECK 2000 <br />11a. TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />y (04cco-tj 9 — S <br />1 <br />�i,-e�oov Urns TA4e- <br />\\l <br />21 �oACo 6a -c -J) ON+�r 21L SCAB-' TAtik <br />12. SENSOR 13. CONTRACTOR CERTIFICATION <br />CERTIFICATION <br />Technicians <br />Date L2— I�r�r �iV L I f <br />R Testing Contractor or Company. By' Signature <br />Serial Bensor o TThermal Certification N t 1-� ( n1� ? I �Q W ta,k� of CA�4 SA <br />2 S �CZI I� U • r2z" l rtv. Address JT <br />Certification N <br />PN68 <br />17 <br />