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Y Tight ® S I T E I N F 0 R M A T I 0 N F 0 R M <br />InoculationM( QJ TracerTighte State_t`$q <br /># 3� Technician <br />L ID #: (�, Z License # <br />Tracer Job Sampling <br />State <br />Technician M� Y—(?")"IDaJerTighte MOS 2 License <br />Precision Test ❑ Leak Delineation ❑Depth <br />Site <br />Name <br />to ground water in tank pit Be` ot."a <br />�l <br />Affilliate �" CZ" Q " <br />Site <br />Address 43'1 0. W 1LSOPI W hi City STOcV_-MN State � Zip : 01SZ6 5-- <br />2 / / OS <br />Precision Test ❑ Leak Delineation ❑Depth <br />Inoculation date / 3 ( / ®s <br />to ground water in tank pit Be` ot."a <br />�l <br />Initial Test All Water Ingress ❑ <br />at inoculation initial visit <br />/ (in inches): tit in. <br />2 / / OS <br />Depth to ground water in tank pit Ge'la" D <br />at sampling/second visit (in inches): (qzl` in. <br />(see box at right) <br />Annual Teat <br />Monthly Monitoring ❑ <br />Sampling date <br />To be used for ALL Water Ingress Tests <br />Retest ❑ <br />Result Verification ❑ <br />Maximum Sample Vacuum <br />Tank(s) were constantly & completely ❑ <br />Residential Tanks <br />() ❑ <br />(Highest probe Vacuum on site) in Hg <br />submerged in ground water for the LZSj <br />duration of the test ? YES NO <br />-t <br />®� <br />k o d <br />8 y <br />. 6a <br />' y <br />" <br />m o <br />0 <br />�;. <br />d me <br />ya` <br />.+ i• <br />o <br />, <br />"°' <br />At inoculation <br />At sampling <br />�, <br />0 <br />H r. <br />.4 ti ® <br />0 0 a V <br />o.. <br />.e y <br />e 0 " <br />a roBoe <br />Tank No. <br />Product <br />Oo,p <br />o <br />Volume <br />' a ] <br />b <br />m <br />n o <br />O <br />$ ^ P <br />C C m <br />c+ w <br />n <br />y p ® <br />O r. <br />" n " <br />O w <br />6 y <br />H 0 level <br />E <br />otal lA u! <br />4 <br />H O level <br />2 <br />Total Liquid <br />Q <br />o ti <br />(in gallons) <br />,m,,. <br />c w 0 <br />m <br />c <br />u 0 g <br />p c; o <br />in tank <br />level <br />in tank <br />level <br />�y ball <br />K <br />G a m <br />W m <br />; a ry <br />in inches) <br />(in inches <br />(in inches <br />(in inches <br />in <br />o c' m <br />0 ft. <br />o <br />A <br />YES <br />12,00a <br />(o;�ZS` - <br />E�3� <br />t <br />Nti <br />3y-6« <br />�� <br />561 <br />W o <br />� o <br />197-`� <br />.�� <br />° � <br />(2,000 <br />(0, 25` <br />CqL�o <br />( <br />C) <br />sg ` <br />2�„ <br />'���` <br />3O,1 <br />1 <br />No <br />NO <br />+l <br />(q2 <br />YNS <br />❑ ❑ <br />NO <br />F-10 <br />1:1 1:1YE3 <br />YES NO <br />YES NO <br />El EJ <br />❑ <br />❑ ❑ <br />YES NO❑ <br />YES NO <br />YES NO <br />❑ ❑ <br />YES NO <br />❑ ❑ <br />❑ ❑ <br />YES NO <br />YES NO <br />El <br />00 <br />US NO <br />El❑ <br />YES No <br />YES NO <br />❑ ❑ <br />❑ ❑ <br />❑ ❑ <br />YES NO <br />Y84 NO <br />YES NO <br />❑ ❑ <br />El <br />❑ ❑ <br />❑ ❑ <br />YES NO <br />YE9 NO <br />YB3 NO <br />Comments :------------------------------ <br />---------------------------------------------------------------------------------------------------------- <br />-- ---------------------------------------------------- <br />Revised 8-27-98 Rev. 03 Tijeer RCSC8rC1l CdrQOritiol <br />L <br />11 <br />