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Data Cha r Tank Systrt fo' em Tightness Test <br />CALIFORNIA CONTRACTORS <br />(21 <br />PLEASE PRINT <br />1. OWNER <br />.v. � �� � r ---mei■,nam i7�*T,} <br />2.OPERATOR <br />TEST RESULTS. <br />w— <br />all <br />-40-A" PUA�W <br />TM <br />,a,n, <br />Address <br />T "� <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />Tta Company or Affiliation <br />Date <br />TEST AND WHEN <br />Telephone <br />Address <br />identify by Direction <br />Capacity Brand/Supplier Grade <br />Approx. Age <br />Steel/Fiberglass <br />5. TANK INVOLVED <br />a f f <br />C. <br />Use additional lines <br />�V ry r <br />for manitolded tanks <br />Location <br />Cover Fills Vents <br />Siphones <br />Pumps <br />` %L iO <br />6. INSTALLATION <br />5 c) vT /-f Cv S t <br />�/ Ji �i <br />Cts yt c /1 fr. T �fe.". .� <br />f7D <br />/ <br />�'�G it qf . <br />DATA <br />ino'r7f-'2 OF <br />ST -P, <br />Roe <br />North Inside driveway. <br />Concrete, Black Top. Bice, Titeall make, Drop <br />Earth. etc. tubes, Remote Fills Size. Manifoided <br />Which tanks? <br />Suction, Remote. <br />Make M known <br />Rear of station. etc. <br />Is the water over the tank? <br />7. UNDERGROUNDnp <br />®Yes No <br />WATER <br />Depth ogowater same <br />Tonka o to filed <br />hr. Date Arranged by <br />NOW <br />Telephone <br />8. FILL -UP <br />ARRANGEMENTS <br />Eats product to vp ow tank meter. tow and who to provide? Consider NO Lead. <br />Terminal or other contact <br />for notice or inquiry <br />Name <br />Telephone <br />comp" <br />9. CONTRACTOR, <br />MECHANICS, ' <br />any other contractor <br />Involved <br />Signature of Tester. <br />�A,_ 3_ <br />10. OTHER <br />" <br />INFORMATION <br />OR REMARKS <br />Additbnhel Mnforrnston on any Items above. iNliciais or others lobe advkrod wthah testing a M or oornptek�. Visaors or observers Prahront during test11. <br />12.SENSOR <br />CERTIFICATION <br />oat. <br />3.71da M eo tafak fN mase title f lea by <br />wa+a tam on th. dat.(s<) Ntowati 7tnoa <br />v} <br />r Me . <br />Technicians Sacramento Equipment 1*6+enance Compare Inc. <br />y� 2533 Connie DdVb" °. <br />Catiacaaa+ a <br />Sacramento, Califorrnl# 8.16 t` <br />Cerbaeation a (916) 925 27* �i <br />