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PLEASE PRINT <br />1. OWNER property ❑ <br />j <br />Tank(s) ❑ <br />2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />AM <br />ata Chart for Tank Sysilm Tightness Test <br />N <br />Address <br />Zip <br />Representative <br />Telephone <br />Name <br />Address <br />Zip <br />Representative <br />Telephone <br />TTee�lephone <br />/ <br />/� / <br />��/ <br />®� q <br />% G /G cam-✓/ /V� <br />�/G./�'G ( U N� <br />C.: /7" <br />Name <br />Address <br />Zip <br />for manifolded tanks <br />Telephone <br />-- <br />152GU6 <br />1912A <br />Name <br />Title <br />Company or Affiliation <br />Date <br />SiphonesPumps <br />- Address <br />Zip <br />Concrete. Black Top, <br />Earth, etc. <br />Telephone <br />Identity by Direction <br />5. TANK INVOLVED <br />Capaci <br />00 <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />, <br />1` <br />Use additional lines <br />— <br />for manifolded tanks <br />-- <br />Location <br />6. <br />DATA ELATION �i!!0,-- <br />Cover <br />�4ej <br />Fills <br />`//i <br />Vents <br />// <br />SiphonesPumps <br />North inside driveway, <br />Rear of station, etc. <br />Concrete. Black Top, <br />Earth, etc. <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Size, Menifolded <br />Which tanks? <br />Suction, Remote. <br />Make if known <br />7. UNDERGROUND Is the water over the tank? <br />WATER Depth to the water table from grade Sr/yr�n / /) ❑ Yes Xhlo <br />Tanks to be filled ' r hr. -+ ` ° abate Arranged by � ®"~t�� `� <br />.e 8. FILL -UP Name -- - - Telephone <br />i ARRANGEMENTS Extra product to 'lop off' and run tank tester. How and who to provide? Consider NO Lead. <br />Terminal or other contact F_ <br />for notice or inquiry �%(/ /l./ <br />Company Name Telephone <br />9. CONTRACTOR, / '�`v <br />MECHANICS, <br />any other contractor T 0'117'/"r <br />w � 1 <br />involved y' <br />10. OTHER <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 TITS ❑ PETRO COMP ❑QUICK CHECK 2000 <br />Tests were me& on the above tank systems In accordatce with test procedures prescrlbed for <br />11a. TEST RESULTS as detailed on attached test charts with resuift as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />V-5,5 <br />12. SENSOR 1C N T <br />CERTIFICATION <br />4`�-9U <br />s � <br />1. <br />/ 7 -oz -a <br />f Testing Contractor or Company. By: Signature <br />Serial No. of Thermal Certification a ENM <br />l/ <br />Sensor ® BOX B <br />9 <br />2 R . $ Address <br />SAMMENTO.CAUFORNIA95M <br />Certification s <br />PN6827 <br />