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Data Chart for Tank Syste St <br /> AUG 0 4 1988 <br /> ,PLEASE PRINTfi— <br /> 'x <br /> HEALTH <br /> I. OWNER, Property C IT/ VICES <br /> Tank(s)❑ Nam tlr s 1`11111presentative Telephone <br /> Na a Address "•.. <br /> presentative Telephone <br /> 2. OPERATOR _ <br /> Name Address Telephone ' <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) --- -- -- <br /> 4. WHO REQUESTED <br /> TEST AND WHEN /Name Title Company or Affiliation Date <br /> -- — Address `) <br /> Telephone <br /> Identify by Direction Capacity Brand/Su Ii GRcle Approx. a Steel/Fjt t9la a <br /> 5. TANK INVOLVED <br /> Use additional lines — <br /> for manifolded tanksINSTA --- _ <br /> tion Cover Fills Vents Siphones Pumps <br /> 6. DATA ELATION G�/L �� AJ <br /> u <br /> North inside driveway, ncrpte,Black Top, Size,Ti Suction,Remote, <br /> Rear of station,etc. Earth,etc. to Remote Fifls Size,Manifolded Which tanks? Make if known <br /> 7. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the water table —_---__-_— ❑Yes <br /> 8. FILL-UP Tanks to be filled_ hr. __ .Date Arranged by_ <br /> Name Telephone ' <br /> ARRANGEMENTS Extra product to"top off'and run tank tester. How and who to provide? Consider NO Lead. <br /> } <br /> Terminal or other contact <br /> for notice or inquiry <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 9ny 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 teat charts with results els follows: <br /> Tank IdentificationTight Leakage Indicated Date Tested '? <br /> ii. <br /> _ c <br /> 12. SENSOR 13.Tw in 110=0=t <br /> o osrtity that tank on the date( Those Indicated as"TiphP•mast the criteria established by the <br /> CERTIFICATION Natbnal fare ProoR11"bT""W-11=281w,c Z7 <br /> TRIANGLE 6(liTee°at)ng(�Cont�r+p�+t>�rCwompcany. B/y:: Signature <br /> Serial No.of Thermal Certification# ^ n� 'a�+• •C✓ �7f'il�Rll�aTVSensor _P_--0 Riia'k�?:�:T }� <br /> 2. SACRAMENTO,CALIFORNIA 9582 <br /> Certification k <br /> PN6827 <br />