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5. TANK INVOLVED <br />Use additional lines <br />for mandolded tanks <br />to <br />.P <br />Tightness Test <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />s <br />PLEASE PRINT <br />D/7Z <br />1. OWNER property ❑ zl <br />S cg <br />Tank(s) ❑ Name //i" � <br />,y0 <br />Address <br />Zip Representative Telephone <br />Nance <br />Lo tion <br />�DG <br />North inside driveway. <br />Rear of station, etc. <br />Address <br />Zip Representative Telephone <br />2. OPERATOR <br />Siphones <br />�� c`�,r <br />Which tanks? <br />&h/`� <br />/f A—)� <br />Name <br />Address <br />Zip Telephone <br />3. REASON FOR <br />�- <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN Name <br />Title <br />Company or Affiliation Date <br />Address <br />Zip Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for mandolded tanks <br />Identify by Direction <br />C's9ty <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />---- <br />6. DATA INSTALLATION <br />Lo tion <br />�DG <br />North inside driveway. <br />Rear of station, etc. <br />Cover <br />Concrete. Black Top. <br />Earth, etc. <br />Fills <br />Size, Titefill make, Drop <br />tubes, Remote Fills - <br />Vents <br />Size, Manifolded <br />Siphones <br />�� c`�,r <br />Which tanks? <br />Pumps % <br />Suction, Remote. <br />Make if known <br />7. UNDERGROUND®� / / of �} la the water over the tank? <br />/� <br />WATER Depth to the water table from grade .}v U— r �— e ` % % ❑ yes XNo <br />Tanks to be filled�H /v <br />ST - 7 hr. l ate Arranged by ®�� ` <br />8. FILL -UP Name Telephone <br />ARRANGEMENTS Extra product to 'lop off' and run tank tester. How and who to provide? Consider NO lead. <br />Terminal or other contact jf 2 n �` ) F, <br />for notice or inQuiry � �/ 6r` <br />Company Name Telephone <br />-2//9 `1.� C� %i Ole-- <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor 0, 2S �� KYDN0T� �'C <br />involved <br />10. OTHER A - <br />INFORMATION <br />OR REMARKS _ <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 PETRO TITE ❑ PETRO COMP ❑ QUICK CHECK 2000 <br />Tests were made on the above tank systems In accordance with test procedures prescribed for <br />112. TEST RESULTS as detailed on attached test charts with results as follows: <br />Tank Identification. Tight _ Leakage Indicated Date Tested <br />12. SENSOR VG I trlt,H I I Iv <br />CERTIFICATION <br />97Te c <br />71 <br />l <br />t ^ Y r 9 <br />Contractor or Company. By: Sig... <br />Serial No. of Thermal Certification a tr G V <br />MMAMWO <br />Sensor l"i RAY ®9f <br />"MMM06 =F Address <br />2ORMA 95M <br />Certification k PN6827 <br />