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Data Chart for Tank Systemi Test <br />PLEASE PRINT <br />Capacity <br />Brand/Supplier Grade <br />Approx. Age <br />1. OWNER property ❑ <br />Tank(s) ❑ <br />NameAddress <br />Representative <br />Telephone <br />Name <br />Address Representative <br />Telephone <br />2. OPERATOR <br />Name <br />Address <br />Telephone <br />3. REASON FOR <br />% <br />TEST <br />Location <br />(Explain Fully) <br />Fills Vents <br />Siphones <br />Pumps <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Name <br />Title Company or Affiliation <br />Date <br />Address <br />Telephone <br />Identify by Direction <br />5. TANK INVOLVED <br />Capacity <br />Brand/Supplier Grade <br />Approx. Age <br />Steel/Fiberglass <br />Use additional lines <br />for manifolded tanks <br />Location <br />Cover <br />Fills Vents <br />Siphones <br />Pumps <br />6. INSTALLATION <br />DATA <br />/�//�-l0 <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 Size, Manifolded <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 <br />tatable <br />� /�,/ E-45 <br />L/LS � v^71 / ' t I �i Jt ❑Yea %�No <br />Tanks to be filled _D 9 he v 45 ` t-6ate Arranged by D `—' _[ ' • " <br />8. FILL -UP Name Telephone <br />? Consider NO <br />ARRANGEMENTS Extra product to 'lop off' and run tank tester. How and who to provide? Lead. <br />Terminal or other contact ��j ) ® /t ��j ) S <br />for notice or inquiry ,{� C® <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <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 />Tests were made on the above tank systems in accordance with test procedures prescribed for <br />11. TEST RESULTS as detailed on attached test charts with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />12. SENSOR <br />CERTIFICATION <br />Date <br />Serial No. of Thermal <br />Sensor <br />2 =;I <br />Certification If <br />PN6827 <br />