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'"',onslruclik %.�umpun <br /> Tes?i n' wA y <br /> Phony(409) 931-1424 licensed <br /> gpost ofto lox 30461 Insured <br /> 4ptocM E Cailloinlo 95213 2 3 x i'�°� ' *92-1248 <br /> r. <br /> OWNER OF SITEt <br /> AUURE^aS! �(:t.'I e' ' Z-���� <br /> OWNER OF TANKS 2 <br /> ALP9JSiEa75! CITY <br /> OPERATOR AT LOCATION: - •_— -- --- __--- —_--- _ <br /> ADDRESS! CITY <br /> t2J <br /> COUNTY! 'DANK ik:_ At=r:_ <br /> -METALuC) riBr!,Rct,AS5Uott13t,r; WAI-4,11 ) <br /> DIESEL( ) UNLEADED( ) t'ttrrtivht uNLr Anr,u( ) ( ) <br /> q . <br /> WASTE OIL(U KEROSENE( ) AVIATION (,AS( ) .fr:r rvEt.,( ) WA,rr.ft( ) <br /> ;SUCTION( ) SUBMERSInr( ) 6VIIttSF't.Lt, CoN'rA].Nrt2�-YES( ) NOW <br /> :� SNEAR#`VALVE--YES( ) NO(A) <br /> 1N •t,trft: 1.1,Alc ur:'rr:r'rr)ft--Yl':S( ) N0(K) « <br /> ` ', 'VAPOR; RECOVERY sYsrEM---xr ( ) Not ) ' 11. Yl,:; , 1,1111S1; t r ) rttn`,r 2( ) <br /> F 4 <br /> y <br /> TANK' FILL DATE T.1 rtE <br /> r <br /> TANK' _ - � ,N1):_�QIJ�1,rN ;'rtt UC' <br /> TANK BOTTOM To GRADE. . . _--- Tr:;;'r f,r:vt;1♦ 'rte IrArfr, 11011'014 <br /> r' ✓ TANK ":'�®�' TO GRAt�E. e : . .� �_/_ - liitt)1)N1) WA 1'f.t2 ABOVE TANK . . <br /> DIAMETER b e l e l e e e e d e . e e e ' 3---- 11.; 1 . • . . . . . . . . . . . . . . . . . . • __. 0 <br /> LEVEL ABOVE GROUND._ ` 1If;'fl r1 �,'►' t'fsEs5vttr . . . . . . . ' � <br /> a:11 WATER -IN TANKeee . eeAPI S `C (IMAV ♦ e . . . , . . . . . .. <br /> 1 :DEPTH FOR TAKING# SAMPLE.^ . . . . . . . . . . . . . . . . . . . . 60 <br /> TEMPERATURE PRO13E DEP'rn �� API c,11Rt' t,t)AV n 60' I' . . 0 <br /> EXt' . . . . . . . <br /> ! ® CERTIFIED TIGHT- "YES(() No( ) 1,F, RAT1; rr•, lttlz: t� / �8 <br /> �,t 'RODUOT LINE TEST--PASS( ) >a A l L( ) SUCT t ON <br /> CERTIFIED TIGHT- -YES( ) No( ) 1,VAI, I?ATV 1'11,12/illi: r 1- <br /> � a ��DATE ,,1��9� sIGNA i vitt of t 1, ,rEt <br /> s r y#f " ' COMMENTS t.,� t <br /> 4 <br /> a , <br /> a <br /> f <br /> REV 3/92 <br /> s r• <br />