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t► - <br />Aa Chart -for Tank SystA Tightness Test <br />PLEASE PRINT 9 ` <br />1. OWNER property ❑ ✓1 r/ � <br />Tanks) ❑ Name 3� l4dd 44 ✓'r� (.01 � C+� Ttlaphone <br />Mame Address Representative Telephone <br />2. OPERATOR NORM Address Telephone <br />a <br />S REASON FOR <br />TEST &eL< <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN "a1e e ( R <br />kterknfy by Direction capacity <br />5. TANK INVOLVED rir ®moo <br />Use additional lines <br />for manffolded tanks <br />r <br />"I <br />L <br />9 Tanks to be tiled tar. ' I ` <br />FILL -UP Date Arranged by <br />& <br />ARRANGEMENTS Extra product to -top otr and run tank tester. How and who to provide? consider No tread. <br />Terminal or other contact / /Q . <br />. for notics oriNuky Company <br />9. CONTRACTOR, <br />MECHANICS, . <br />any other contractor <br />Involved <br />10. OTHER " <br />INFORMATION <br />OR REMARKS _ <br />Addxional inforn atbn on any items above. Officials or otters to be advised when tealinp is In progress or <br />0 <br />Tests woos made on the above tank systems In scowdence with test ptoceduns prwoibed for <br />11. TEST RESULTS an detaaed on attached teat dtrb with result Die <br />Tank Identification Tiftlm . Leakage Indicated r .. <br />.. n .AL w . I� _ — � "[ R /r n6L <br />Telephone <br />i <br />IMMENTAL HEALTH', <br />or observers present durino teat. eta <br />Date Tested <br />12. SENSOR 13.Thin leto.oertlty that s , 1 tank systsnts ten tsded on the dd*) d%:m h.'Rtose as. and the aNst a by the <br />a CERTIFICATION Nallond tyre A"'°d't°n 3M <br />Technicians <br />. Date �. <br />--hA R�lii c Jtl �' <br />Q ` ( /� (�� . A n Testing Contractor CokkpennY. CIA- <br />Sensor <br />� <br />Serial No. Of Thermal CartinaNa+a } `—I Y'r `�M�•` CJ1�i(�11L4k/411 CIA- <br />Sensor <br />Address <br />2 i <br />I <br />cerincatton a PN6827 ? <br />Siphores <br />Pumps <br />Location <br />cover <br />Fills <br />vents <br />6. INSTALLATION <br />DATA <br />( <br />-- <br />North Heide driveway. <br />Concrete. Bleck Top. <br />Size. TtetM make. Drop <br />Suction. Remoter' j <br />. <br />... ...Rear of statim: eta _. <br />' Earth. eta <br />tubes. Remote Fills <br />Size. k4enifolded .. <br />Which tanks? ' <br />-Make N known <br />' 7.. UNDERGROUND <br />- Is the water over the tank? <br />WATER <br />Dgom tone water table <br />U "ti <br />Q res <br />CPN <br />9 Tanks to be tiled tar. ' I ` <br />FILL -UP Date Arranged by <br />& <br />ARRANGEMENTS Extra product to -top otr and run tank tester. How and who to provide? consider No tread. <br />Terminal or other contact / /Q . <br />. for notics oriNuky Company <br />9. CONTRACTOR, <br />MECHANICS, . <br />any other contractor <br />Involved <br />10. OTHER " <br />INFORMATION <br />OR REMARKS _ <br />Addxional inforn atbn on any items above. Officials or otters to be advised when tealinp is In progress or <br />0 <br />Tests woos made on the above tank systems In scowdence with test ptoceduns prwoibed for <br />11. TEST RESULTS an detaaed on attached teat dtrb with result Die <br />Tank Identification Tiftlm . Leakage Indicated r .. <br />.. n .AL w . I� _ — � "[ R /r n6L <br />Telephone <br />i <br />IMMENTAL HEALTH', <br />or observers present durino teat. eta <br />Date Tested <br />12. SENSOR 13.Thin leto.oertlty that s , 1 tank systsnts ten tsded on the dd*) d%:m h.'Rtose as. and the aNst a by the <br />a CERTIFICATION Nallond tyre A"'°d't°n 3M <br />Technicians <br />. Date �. <br />--hA R�lii c Jtl �' <br />Q ` ( /� (�� . A n Testing Contractor CokkpennY. CIA- <br />Sensor <br />� <br />Serial No. Of Thermal CartinaNa+a } `—I Y'r `�M�•` CJ1�i(�11L4k/411 CIA- <br />Sensor <br />Address <br />2 i <br />I <br />cerincatton a PN6827 ? <br />