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PLEASE PRINT <br />1. OWNER Property ❑ <br />Tank(s) ❑ <br />01 Data Chart for Tank is Tightness Test <br />Address Zip Representative <br />Name" Address Zip Representative <br />Telephone <br />2. OPERATOR cf i "`'' %,L�v`„ --- <br />Name Address Zip Tefopffons <br />3. REASON FOR - --- — <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Name Title Company or <br />Address Zip <br />Identify by Direction <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Capacity <br />Brand upptier <br />Grade <br />Approx. Age Steel/F' er ass <br />— -- <br />-- <br />L r <br />6. INSTALLATION 4Wj, <br />DATA � <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />Size, Titefiit make. Drop <br />tubes. Remote Fills <br />Vents <br />Size, Manifolded <br />Siphones Pu <br />®w�` <br />ALL <br />Suction, Remote. <br />Which tanks? Make if known <br />7. UNDERGROUND /� / Is the water over the tank? <br />WATER Depth to the water table from / l" G --L— L1 Yes .hJ No <br />6. PILL -UP Tanks to be filled V hr. Xte Arranged by <br />Name Telephone <br />ARRANGEMENTS Extra product to "top off' and run tank tester. How and who to provide? Consider NO Lead. <br />g <br />Terminal or other contact A ll I/ )� <br />for notice or Inquiry <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS --- <br />any other contractor <br />f � <br />Involved <br />10. OTHER <br />INFORMATION — <br />OR REMARKS <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 PETRO TIT>� ❑PETRO COMP ❑QUICK CHECK 2000 <br />Tests were made on the above tank systems In accordance with test procedures prescribed for <br />11a. TEST RESULTS as detailed on attached test charts with results as follows: <br />Tank Idenlili ation Tight Net Volume Change Per Hour j Date Tested <br />.12. SENSOR 13. CONTRACTOR CERTIFICATION TRIANGLE INC. OF SACRAMENTO <br />CERTICA 10N, P.O. BOX 231067 <br />/_ hn a SACRAMENTO, CA 95823-1067 <br />a ® , t <br />, Testing Contractor or Company. By: Spn <br />aaluro <br />Se al No. of Thermal Certification `= <br />Sensor <br />Address <br />r <br />Certification a PN6827 <br />