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- <br />Identify by Direction <br />Capacity <br />Brand/ pplier Grade <br />Approx. Age <br />Steel/Fiberglass <br />— <br />art f <br />_atan <br />Tightness <br />- <br />� 1 <br />6. INSTALLATION®� <br />DATAy�DA'i <br />Lac"on <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />Concrete, Black Top, <br />Earth, etc. <br />t <br />PLEASE PRINT <br />s e ? <br />a� f <br />Pum <br />Suction. Remote, <br />Make if known <br />1. OWNER Property ❑ <br />Tank($) ❑ <br />Address Zip <br />Representative <br />Telephone <br />Name <br />Address Zip <br />Representative <br />-Telephone <br />® <br />G <br />2. OPERATORZxF <br />N a <br />Address Zip <br />Telephone <br />3. REASON FOR <br />—� - <br />TEST <br />(Explain Fully) <br />4. WHO REOUESTED <br />Name <br />—��/�Lp• - <br />Title Company <br />'` <br />or Affiliation <br />Dale <br />TEST AND WHEN <br />Address Zip <br />Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identify by Direction <br />Capacity <br />Brand/ pplier Grade <br />Approx. Age <br />Steel/Fiberglass <br />— <br />- <br />6. INSTALLATION®� <br />DATAy�DA'i <br />Lac"on <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />Concrete, Black Top, <br />Earth, etc. <br />Fills Vents <br />��° <br />Size, Titefill make, Drop <br />tubes, Remote Fills Size, Manifolded <br />Siphones <br />�j��✓� <br />Which tanks? <br />Pum <br />Suction. Remote, <br />Make if known <br />J <br />7. UNDERGROUND s me warer over „'e o r <br />WATER Depth to the water table frro`m-�gra� <br />11 Yes �/J' No <br />8. FILL -UP Tanks to be tilled t hr. / / —Dale Arranged by <br />Name Telephone <br />ARRANGEMENTS Extra product to "top off' and run tank tester. Flow and who to provide? Consider NO Lead. <br />Terminal or other contact A—,)( -) <br />A <br />for notice or Inquiry //L/C./) -) A_) — <br />Company Name Telephone <br />9. CONTRACTOR, /,/ -A—U. CQr <br />MECHANICS, <br />any other contractor <br />Involved —t— <br />10. OTHER <br />INFORMATION <br />OR REMARKS — <br />Additional infor 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 TITFL;�T_ ❑ PETRO COMP T—DOUICK CHECK 2000 <br />Tests were made on the above tank systems in accordance with test procedures prescribed for <br />Ila. TEST RESULTS as detailed on attached test charts with results as follows: <br />Tank Identification Tight Net Volume Change Per 1 -four Date Tested <br />4:11 <br />11 1 <br />12. SENSOR 13. CONTRACTOR CER KATION 12. INC. OF SACRAMENTO <br />CERTIFICATION P.O. BOX 231067 <br />1? ISACRAMENTO, CA 95823.10 s 6" <br />//J, Testing Contractor or Company. By: Signature <br />rial No. of Thermal Certification MZ <br />Sensor 14U91 <br />Address <br />Certification 0 PN6827 <br />