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- <br />ata <br />Chart for Tank Sysbn <br />Tightnesss <br />(trade <br />PLEASE PRINT <br />Steal/Fiberglass <br />1. OWNER Property ❑ <br />- <br />Tank(s) <br />Address Zip <br />Representative <br />Telephone <br />Name <br />Address Zip <br />Representative <br />Telephone <br />2. OPERATOR41P <br />Fills <br />Size. Titefill make, Drop <br />tubes, Remote Fills <br />® <br />Siphones <br />Which tanks? <br />G <br />Whe <br />Address Zip <br />Telephone <br />3. REASON FOR <br />4 tT <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN NB11e <br />Title Company <br />or Affiliation <br />Date <br />Address Zip <br />Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identify by Direction <br />Capacity <br />BirandiMppiclier <br />(trade <br />Approx. Age <br />Steal/Fiberglass <br />6. INSTALLATION <br />DATA <br />Aon <br />/ a <br />Northinside driveway, <br />Rear of station, etc. <br />Cover <br />Concrete. Black Top. <br />Eanh, etc. <br />Fills <br />Size. Titefill make, Drop <br />tubes, Remote Fills <br />Vents <br />Size, Manifolded <br />Siphones <br />Which tanks? <br />Pum <br />�f <br />Suction, Remote. <br />Make if known <br />7. UNDERGROUNDIs the water over the tank? <br />WATER Depth to the water table from gra`�0 //%/ C Y. 10 No <br />8. FILL -UP Tanks to be filled rYhr. ` Date Arranged by Name Telephone <br />ARRANGEMENTS 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, 1 `;�,'4 LZ <br />MECHANICS, <br />any other contractor ® i <br />involved <br />10. OTHER l <br />INFORMATION <br />OR REMARKS — <br />Additional inror ation 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 joPETRO TIT€7PETRO COMP =E1 ICK CHECK 2000 <br />Teats were made at the above tank systema In accordance with test res prescribed for <br />11a. TEST RESULTS as detailed an attached teat charts with results as follows: <br />Tank IdentificationYight _ Net Volume Per Has Date Tested _ <br />12. SENSOR <br />CERTIFICATION <br />S6rIaI No. of Thermal <br />Sensor <br />13. CONTRACTOR CER ICATION GLE E <br />NM <br />h e P.O. BOX 231(*7 <br />T0, CA 958231 - 'k, 6" <br />Testing Contractor or Company. By: Signature <br />,^,erllflcallon s <br />yi'% /! //r Address <br />Z � G/ <br />Certification e <br />