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0 0 <br />Data Chart for Tank System Tightness Tel <br />PLEASE PRINT <br />Capacity <br />1p <br />Brand/Supplier <br />�e <br />Grade <br />�/Z <br />, <br />1. OWNER Property ❑ <br />� T <br />Serial No. of Thermal <br />Sensor <br />Certification k <br />0 <br />Tanks) ❑ <br />Name/' YP � <br />/f ,� /�/,/j"� <br />Address Zip <br />Representative <br />Telephone <br />Name <br />Address Zip <br />Representative <br />Telephone <br />2. OPERATOR <br />/ %A --1/t1 17 <br />- <br />Name <br />Address Zip <br />---------- <br />Telephone <br />3. REASON FOR <br />/fJ /g-7`5-5,U7— <br />T <br />Location <br />6. INSTALLATION 6/ 1¢�DiG' <br />DATA <br />TEST <br />TEST <br />Fills <br />�j <br />Vents <br />�t // <br />Siphones <br />/V�j�% <br />Pump <br />1`�D 49 <br />(Explain Fully) <br />C/ <br />4. WHO REQUESTED <br />North inside driveway. <br />Concrete. Black Top, <br />Size, Titefill make, Drop <br />TEST AND WHEN <br />Name <br />Title <br />Company or Affiliation <br />Date <br />Size. Manifotded <br />Which tanks? <br />Address Zip <br />Telephone <br />Identity by Direction <br />5. TANK INVOLVED — <br />Capacity <br />1p <br />Brand/Supplier <br />�e <br />Grade <br />�/Z <br />Approx. Age <br />x? <br />Steel: Fiberglass <br />� T <br />Serial No. of Thermal <br />Sensor <br />Certification k <br />0 <br />Use additional lines <br />for manifolded tanks <br />- <br />---------- <br />Location <br />6. INSTALLATION 6/ 1¢�DiG' <br />DATA <br />Cover <br />�i_ .� <br />(.� <br />Fills <br />�j <br />Vents <br />�t // <br />Siphones <br />/V�j�% <br />Pump <br />1`�D 49 <br />C/ <br />North inside driveway. <br />Concrete. Black Top, <br />Size, Titefill make, Drop <br />Suction. Remote. <br />Rear of station, etc. <br />Earth, etc. <br />tubes, Remote Fills <br />Size. Manifotded <br />Which tanks? <br />Make if known <br />7. UNDERGROUND IUD <br />, ✓A , //� Is the water over <br />tth(e tank? <br />v <br />, <br />WATER Depth to the water table from grade D vM 4 ❑ Yes �Sl No <br />11 <br />Tanks to be filled hr. � Date Arranged by v <br />8. FILL -UP Name Telephone <br />ARRANGEMENTS Extra product to 'top off' and run tank tester. How and who to provide? Consider NO Lead. <br />Terminal or other contact /w <br />for notice or inquiry {/S <br />d `y <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />10. OTHER ®vvav <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 made on the above tank systems In accordance with test procedures prescribed for <br />11a. TEST RESULTS 9 as detailed on attached test charts with results as follows: <br />Tank Identification % Tight Leakage Indicated Date Tested <br />_, <br />/ 5 l I i / <br />12. SENSOR <br />ONTRAI <br />CERTIFICATION <br />LICIM ft i <br />To <br />Serial No. of Thermal <br />Sensor <br />Certification k <br />0 <br />Certification k <br />ly � <br />�111`13y: Signature <br />TRIANGLEg <br />a <br />PN6827 <br />