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,SIF <br />a <br />rvv_ P \ 1 • <br />(PI <br />RECEIVED <br />1992 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />PLEASE PRINT <br />1. OWNER Property ❑ <br />Na <br />Tank(s) ❑ <br />Name <br />0 0 <br />Data Chart for Tank System Tightnesst <br />ECEEIVE <br />JUN 01 IM <br />Address Zip <br />Address Zip <br />Telephone <br />Telephone <br />2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />Name Address Zip Telephone <br />4. WHO REQUESTED <br />TEST AND WHEN <br />- <br />Name Title Company or Affiliation Date <br />Address Zip Telephone <br />5. TANK INVOLVED <br />Use additional lines for manifolded tanks <br />3 <br />Capaci Brand/Sup liar <br />Grade <br />Approx. A e <br />® <br />Spl <br />N <br />t <br />0 <br />6. DATA INSTALLATION <br />- <br />n <br />l�-- ® <br />North inside driveway, <br />Rear of station, etc. <br />Cover Fills <br />r/� <br />Concrete. Black Top. Size, Titefill make, Drop <br />Earth, etc. tubes. Remote Fills <br />Vents <br />/i <br />Size, Manifolded <br />Siphones <br />LG% <br />Which tanks? <br />it <br />a <br />rvv_ P \ 1 • <br />(PI <br />RECEIVED <br />1992 <br />ENVIRONMENTAL HEALTH <br />PERMIT/SERVICES <br />PLEASE PRINT <br />1. OWNER Property ❑ <br />Na <br />Tank(s) ❑ <br />Name <br />0 0 <br />Data Chart for Tank System Tightnesst <br />ECEEIVE <br />JUN 01 IM <br />Address Zip <br />Address Zip <br />Telephone <br />Telephone <br />2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />Name Address Zip Telephone <br />4. WHO REQUESTED <br />TEST AND WHEN <br />- <br />Name Title Company or Affiliation Date <br />Address Zip Telephone <br />5. TANK INVOLVED <br />Use additional lines for manifolded tanks <br />Identity by Direction <br />,i l <br />Capaci Brand/Sup liar <br />Grade <br />Approx. A e <br />Steel/Fibergl s <br />6. DATA INSTALLATION <br />- <br />n <br />l�-- ® <br />North inside driveway, <br />Rear of station, etc. <br />Cover Fills <br />r/� <br />Concrete. Black Top. Size, Titefill make, Drop <br />Earth, etc. tubes. Remote Fills <br />Vents <br />/i <br />Size, Manifolded <br />Siphones <br />LG% <br />Which tanks? <br />Pump <br />7c� <br />Suction, Remote. <br />Make if known <br />7. UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the water table from grab `� %' 1.�9/❑ Yes , No <br />r <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. 1S ` � e Arranged by <br />Name Telephone <br />Extra product to 'lop off' and run tank tester. How and who to provide? Consider NO Lead. <br />Terminal or other contact ¢� /I i <br />for notice or inquiry / v (,/ / �J <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />— <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 <br />9 PETRO TIT <br />F0 PETRO COMP <br />❑QUICK CHECK 2000 <br />11a. TEST RESULTS <br />Tests were made on the above tank systems In accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Tank Iden 'fication Tight Net Volume Change Per Date Tested <br />12. SENSOR <br />`CERTIFI <br />:.13. CONTRK%A#tC5Q3i[JI �4 <br />PAIMMMOU <br />Serial No. of Thermal Certification s ®� <br />Sensor <br />2 <br />Certification s <br />Testing Contractor or Company. By: Signature <br />Address <br />