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chata Chart for Tank SyNem Tightness Test <br /> PLEASE PRINT <br /> A <br /> 1. OWNER Property❑ �A(`� <br /> rl <br /> Name AddressRepresentallve Telephone <br /> Tank(a) 1. _1 T HLAITH <br /> Name Address Repnssentlilwo FERMI /•SERVI(DE48hone <br /> LD7-,4 30350 TRACY BLVD ->- Ac if Zo9- 835 - <br /> 2. OPERATOR Name Address Telephone <br /> 3. REASON FOR Ai,I�TE�t/A�t/GE <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> Name Title Company or Affiliation Data <br /> TEST AND WHEN + <br /> Address Telephone <br /> Identify by Direction Capacity Brandi$uoplier Grade Approx.Age Steel,Fibergiass <br /> 5. TANK INVOLVED ?i /ZEAR or YARD /000c:�, DIESEL <br /> 3EAR Nat PLA uT /Gbo L <br /> Lha additional lines EAR 6h' R46e 70G0 L <br /> for manitolded tanks �LEAa EQ <br /> ,11W FF1cE lDoo wA E �� <br /> qf-AV nF <br /> R Cover hones Pumps <br /> Location Fills Vents Sio <br /> N Z O5 C -`1 ' <br /> 6. INSTALLATION +y1 DS-RE/IRoFYA,tO suc?'1o�- -4:5 46,C) <br /> aZDSL-NorPLA"7- EA2TH d7-osL -3'' Z 't iUQ <br /> DATA a 3DU-WA5N RAc� y 3 pL5L- y" <br /> vaLEAOEp- o�FrcE <br /> W,4 7-Z iG •RM'i?MAC Suction.Remote. <br /> North inside driveway. Concrete.Black Top. Sixe.Titafin make,Drop Which tanks? Make if known <br /> art <br /> Rear of station,etc. Eh,etc. tubes.Remote Fills Size,Manilofded <br /> Is the water aver the lank? <br /> 7. UNDERGROUND /sz/ 7- ❑Yes No <br /> WATER Depth to the Water table <br /> Tanks to be filled hr. Data Arranged by Name Telephone <br /> 8. FILL-UP <br /> ARRANGEMENTS Extra product to'lop off and run tank tester. Now and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry Name Telephone <br /> Gdmpany <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any nems above.Officials or others to be advised when testing is In progress or completed visitors or observes present during lest.etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on attached teat charts whh results as follows: <br /> Leakage Indicated Date Tested <br /> Tank Identification Tight g SA� pQ <br /> 6. H. - SAN <br /> L o 19 <br /> oiESE7'� Nf ' oz7o G•PN 8 <br /> 3� o Z Yo G g P H 3 �A.tJ <br /> L Ti /H T 3 SA.t/ 89 <br /> UNLEAD D 3 SA,r>89 <br /> 12. SENSOR 13.Tbla ts to cerUty that dv*"tank systerm w"o totted on the dase te($)shown.ThoIndkated as-Nhr meat the crtterta established by the <br /> CERTIFICATION National We Protection� �'' Pertsphlrt <br /> Technicians <br /> Dae y3 D5L /93Z t MARK S fAtit1 BEc KER stlOv s?'R iE5•' / ` <br /> ar X DSG-1932 Testing Contractor or Company By: Signature <br /> rzosc 677 y/y8/ 9 <br /> $anal No of Thermal Certlfiution a 3'/08 zs0/ oAK T <br /> Sensor Address <br /> Z Kc-VIAI cLArPKE <br /> Cer.'hCalron• .._._.. _. <br />