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tats Chart for Tank System Tightness <br />Test <br />LEASE PRINT STATION ION <br />DATE <br />1. OWNER P ,.,,,. ❑ <br />Trik(s) ❑ <br />Tefaphaw <br />� Address Reonaa Ut" <br />I <br />Name Address RepressntatM <br />T. M <br />2. OPERATOR <br />Nem. Address <br />Tsleplwne <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />'j 4. WHO REQUESTED <br />TEST AND WHEN <br />Title CompenpW Affiliation <br />Date <br />Address <br />Telephone <br />5. TANK INVOLVED <br />Identify W Direction <br />Capacity <br />Bnnd/Suppher <br />Graf �,:' <br />Approx. Aq <br />Steel/Fibarglass <br />r <br />Use a1ldkbnal irtea <br />4 tow mantlolded tanks <br />- <br />loptbn <br />Cesar <br />FiM <br />verve <br />6. INSTALLATION <br />Siphon.. <br />Ptd <br />DATA <br />{ <br />North 4nide dNvwa. <br />Rwr of station. eta <br />Connate, BlarA <br />Earth, at <br />Ske, Ydefie mala. Drop <br />tubas. Flaatola Fift <br />Size. 14nwbWed - - <br />Which tarns? <br />Suction, MmoW <br />Make M kno- <br />7. UNDERGROUND <br />WATER <br />Is the wMer over the tank? <br />Depth to the water table <br />❑ Yes ❑ No <br />b I <br />' 8. FILL-UP <br />Tanks lo be faW hf Date Anangee try <br />ARRANGEMENTS <br />I <br />Exha product to -top ane nm ter taw. flow and -ho to provide? Certeteer NO Lexi Nen+. <br />Tat.pnorr <br />f <br />TarnWul or contact <br />for notice or <br />.. <br />Company Name <br />Telephone <br />9. CONTRACTOR, <br />j MECHANICS, <br />My oftW contractor <br />_ <br />C <br />- <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />-- -- <br />Addition" Informatgn on any, ita Wove. Official or other b be advised when testing . in programs or compNled. Vbaon or observen Present dur" tela. etc. <br />11. TEST RESULTS <br />Tests Here ^' on the above tank "erns in accordance wtth test prOOWU"pnseftbed for <br />a• defalled on attached tat charts with results as follows: <br />i <br />Tank Identification Tighl leakage Indicated pale Tested <br />12. SENSOR <br />13. This N to cetWy that thee` tw* "am wen tested on the dats(s) showf. Those Indicated -NW <br />CERTIFICATION <br />as i th! Cdteda <br />National Rate IsMUCtbn Anodwdm pentlPh4t 3251 <br />litstablished by the <br />Technician <br />Date <br />_ Terwv 9ontrecux or Company. By: Signature <br />Serial No. of Thermal <br />sense, <br />Ce.urutio„. 1919 MA2KET 51 DA41 A9 A <br />2 Aadrey <br />CMtlfiGilOn a <br />PN682 <br />