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Data Tank em Tightness Test <br />IONDIALYSIS NORTH <br />P.O. Box 95 • Bella Vista, CA • 96008 <br />PLEASE PRINT (916) 2756667 <br />1. OWNER pro arty ❑ - }L%c`J tiJ <br />Tankb) ❑ Name Address Representative Telephone <br />Name Address. R"rese native Telephone <br />2. OPERATOR _ A 4 N0. to S-roct►Tom , <br />NemsAddress Telephone <br />3. REASON FOR IU E tAl 'TiZ LA S C 0 0 A <br />TEST t�8'12AI�I <br />= T� � 4 �T�7> � T16 N w"ai C <br />(Explain Fully) —r r. ,... / .0 ,_ <br />f t�/1�r3 iii i%�' d'i7 /'� � 1 A�i'}� is � �'e L. � ,"::�F>e� .,sy�d s4. WHO REQUESTED F2d N wN c P o L;. C'batl "TEST AND WHEN Two Company or Attiliatowe <br />ZO rva I,t L ' A <br />Addnms Telephone <br />Identify by oirection <br />capacity ermwisupprw <br />Gratia <br />Approx. Age <br />Stasi/Rtrergiaes <br />5. TANK INVOLVED g w ils-j-; <br />_-00 4rW // '0sj <br />W <br />N Grwj <br />t k <br />v„J Li i'.Y itoX) <br />w ArIr <br />A.iZAJ <br />A+toi2!' <br />LAS ,�L <br />i..., <br />l <br />L ry.``�.: <br />Use additional linesc <br />for manitolded tanks <br />A4- CASX <br />11, tooth A - V a ki <br />yjA'rz- <br />ou ew <br />15L A S :e <br />Location <br />6. INSTALLATION,1 <br />DATA F12A <br />cow Fila <br />C.O�G <br />Vents <br />Z' 1 <br />Nu <br />Siphoned <br />N®Nk- <br />Pumps <br />ivasIAja <br />North inside driveway. <br />Rea Of station. etc. <br />Concrete. Black Top. Site. Titefill make. crop <br />EsroL etc. boas. Remote Film, <br />Sin. Manifolded <br />Which tanks? <br />Suction. Remote, <br />Maks if known <br />7. UNDERGROUND <br />WATER <br />8. FILL -UP <br />ARRANGEMENTS <br />9. CONTRACTOR. <br />MECHANICS, <br />any other contractor <br />involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />11. TEST RESULTS <br />12. SENSOR <br />CERTIFICATION <br />Oats <br />Serial No. of Therms <br />Sensor <br />Is the water over the tank? <br />Depth to the water tabN UN K a J W ti ❑ yes `i,No <br />Tanks to be feed hr. Does Arranged by <br />Name Telephone <br />Extra product to 'top otr and nun tank taper. Mow ana who to pram? Consider NO Lead. <br />Terminal or oma co ntect <br />for notice or irwluiry - Company Name Telephone <br />2� CtG !a IS Ga /ro/}1 04 M e5 <br />INST,a4L&-T> P44 A A& L MAutFJL T,-, 'z f I Z"# <br />T"iAJ Lliv A1204 ZINC S <br />Additional inf pia+ an wry items above. Officiabror others to be advised when testing is in prognme or completed. Visruml or observers present during tat. etc. <br />Taab wan made on On above tank system In accordonft with ted procownes prow"bad for <br />as detallecl on aftn&ad ted chests wee reenift n todowc <br />Tank Idanbfleation Tight Leakage tndieaad rows Team <br />® tai Aj a <br />tato a 0 a <br />�.®'L.twAna y. P11� a� �' � 170 <br />�e <br />r_Ir <br />Its <br />l <br />y DIALysis M081990, <br />k <br />�..,�. P.O. - . -_, ft% •.sex <br />PERMIT <br />t <br />