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ftEASE PRWTI* v <br />I. OWNER ftwv [D <br />Tankgt <br />2 OPERATOR <br />3. REASON FOR <br />TEST <br />rt911+11% fwb) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />5. TANK INVOLVED <br />Lice additbMl Ilnec <br />for nwnHadW tanks <br />6. INSTALLATION <br />DATA <br />7. UNDERGROUND <br />WATER <br />8. FILL. -UP <br />ARRANGEMENTS <br />9. CONTRACTOR, <br />MECHANICS, <br />eny Other Contractor <br />invotmd . <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />11. TEST RESULTS <br />• ver =. .� . t i`f <br />` `.`: a`:>t•2 14K•: •t1.`S•: :•3 `ti•'`it. }w titi`:2 itis: <br />.r>r......> „r rSi1. .. . t., Vii.. 4 irE+wr�f�v>.Y<•.rE{2>..Sir,{2.21.•2iiS..h2{t>t1,Yu{ SYtYr.r ,..,.. .rirY... 2.2Y.. . , :.tt` . r.f;r .2<2. • ..tr 2{ <br />1:100for Tank System Tightness Test <br />ENVIRONMENTAL HEALTH <br />PERMIT / SERVICES <br />Y //l 0O <br />Nanw <br />IleprwNatWe TeMpibne <br />5� c <br />fkv W <br />WOW peeps <br />r <br />SrfcMon, fonbM, <br />Which tante? Nate it known <br />N the water over the tank? 1 . <br />oyM ONO . I <br />Tanks to be Wad. «Oij . hr. C/— y? Data Arranged by _ � Ao P V v p R, . <br />no <br />Exna product b 'top otr' and nm ster. b pr <br />tank taNow and who uvldS? CorWw dNO La WNaTegphone <br />Terminal or other oontad <br />.for notice ofirwAft - <br />pony <br />AM"Wwl iaton"Ok'n on any Moms above. Officok or ethm b be S&I"d when oatkp is in propreq or <br />Teaphone <br />or obaeven preearrt during oet. etC. <br />Teeb Wwe made an Mte atfpve UK* systems In a000rdwx* with ted procedures prescribed for <br />res d@UNW on attt ched test charts with resins res ?cloves: <br />Tank Identification Tipw Laakape kWMcsted OSte Tested! <br />�oF e o 6- <br />9=6-� <br />OF 2 00q <br />3aF3 EEEIr LL n f_ <br />2 SENSOR 13. Thio N b.osrflty that Ithaca tttrltt ayst«ns wftns tttabd on Vw dot*) tfhowrt, Those kWk@W r <br />CERTIFICATION f Nwon� R"' AoMoMon Anotitllon ft 10 3M 'itOttC'tt?aat alfa fxMata WSW" by Lha <br />Technician <br />Date <br />q Tilt Ow*acbr W <br />Gro.o.nan. T /�f �/ z �y�! / t ( .S°a"pFr'y. °'c sphw"/" <br />l3arleor <br />6. <br />2 Ad&vn <br />AddnN <br />pati <br />szo? <br />klenft by Direction <br />Gpadq. <br />Onndr-wpow <br />Graf <br />SteN/NbSrow, <br />2©F <br />47 <br />r <br />Location <br />Cover <br />Flan <br />vents <br />AlE. <br />6' 0 ,,c- 're <br />�" � <br />� ig <br />prat"s p L oT <br />North l Bide driveway. <br />PAW of Station, etc. <br />Comers. Black Top. <br />Farts, eta <br />Srte, TSetia make, prop <br />tubas, emote FIW <br />Size, ManNoldW <br />Depth to the Water taws / 2 V,- F <br />WOW peeps <br />r <br />SrfcMon, fonbM, <br />Which tante? Nate it known <br />N the water over the tank? 1 . <br />oyM ONO . I <br />Tanks to be Wad. «Oij . hr. C/— y? Data Arranged by _ � Ao P V v p R, . <br />no <br />Exna product b 'top otr' and nm ster. b pr <br />tank taNow and who uvldS? CorWw dNO La WNaTegphone <br />Terminal or other oontad <br />.for notice ofirwAft - <br />pony <br />AM"Wwl iaton"Ok'n on any Moms above. Officok or ethm b be S&I"d when oatkp is in propreq or <br />Teaphone <br />or obaeven preearrt during oet. etC. <br />Teeb Wwe made an Mte atfpve UK* systems In a000rdwx* with ted procedures prescribed for <br />res d@UNW on attt ched test charts with resins res ?cloves: <br />Tank Identification Tipw Laakape kWMcsted OSte Tested! <br />�oF e o 6- <br />9=6-� <br />OF 2 00q <br />3aF3 EEEIr LL n f_ <br />2 SENSOR 13. Thio N b.osrflty that Ithaca tttrltt ayst«ns wftns tttabd on Vw dot*) tfhowrt, Those kWk@W r <br />CERTIFICATION f Nwon� R"' AoMoMon Anotitllon ft 10 3M 'itOttC'tt?aat alfa fxMata WSW" by Lha <br />Technician <br />Date <br />q Tilt Ow*acbr W <br />Gro.o.nan. T /�f �/ z �y�! / t ( .S°a"pFr'y. °'c sphw"/" <br />l3arleor <br />6. <br />2 Ad&vn <br />Anitiation <br />pati <br />szo? <br />TaiNNrore <br />AM. Ace <br />SteN/NbSrow, <br />WOW peeps <br />r <br />SrfcMon, fonbM, <br />Which tante? Nate it known <br />N the water over the tank? 1 . <br />oyM ONO . I <br />Tanks to be Wad. «Oij . hr. C/— y? Data Arranged by _ � Ao P V v p R, . <br />no <br />Exna product b 'top otr' and nm ster. b pr <br />tank taNow and who uvldS? CorWw dNO La WNaTegphone <br />Terminal or other oontad <br />.for notice ofirwAft - <br />pony <br />AM"Wwl iaton"Ok'n on any Moms above. Officok or ethm b be S&I"d when oatkp is in propreq or <br />Teaphone <br />or obaeven preearrt during oet. etC. <br />Teeb Wwe made an Mte atfpve UK* systems In a000rdwx* with ted procedures prescribed for <br />res d@UNW on attt ched test charts with resins res ?cloves: <br />Tank Identification Tipw Laakape kWMcsted OSte Tested! <br />�oF e o 6- <br />9=6-� <br />OF 2 00q <br />3aF3 EEEIr LL n f_ <br />2 SENSOR 13. Thio N b.osrflty that Ithaca tttrltt ayst«ns wftns tttabd on Vw dot*) tfhowrt, Those kWk@W r <br />CERTIFICATION f Nwon� R"' AoMoMon Anotitllon ft 10 3M 'itOttC'tt?aat alfa fxMata WSW" by Lha <br />Technician <br />Date <br />q Tilt Ow*acbr W <br />Gro.o.nan. T /�f �/ z �y�! / t ( .S°a"pFr'y. °'c sphw"/" <br />l3arleor <br />6. <br />2 Ad&vn <br />