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RECEIVE <br /> %a Chart for Tank S sts Tightness Test <br /> OCT 0 5 1992 Y g <br /> ENV[�IIaRON IMSNT(A��L/h(yA}�LTH <br /> PLEASE PRINT [` lfl* I!! f <br /> 1. OWNER Property El LHP io© Tj ox,V 7� t!/ <br /> �Tank(s)❑ Nasme dress Zip presentative Telephone <br /> Name Address7 Zip Representative Telephone <br /> 2. OPERATOR mh 1 <br /> Name Address Zip Telephone <br /> 3. REASON FOR n K,a � <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED1t &K&j,,jeq <br /> TEST AND WHEN Na a Title Company or Affiliation Date <br /> c Ulm <br /> Address Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED S. t 'P p,,PIK Ia-cm <br /> f <br /> Use additional lines -for manifolded tanks <br /> Location Cover Fills �� Vents Siphones Pum s <br /> 6. INSTALLATION i F_VLgI C'.o+�� Ir'�E�P 4 'o1--fit 91 ��N'/��1a <br /> DATA �6lat y1p{ <br /> North inside driveway, Concrete,Black Top, Size,Titefill make.Drop Suction,Remote, <br /> Rear of station,etc. Earth,etc. tubes.Remote Fills Size,Manifolded Which tanks? Make if known <br /> 7. UNDERGROUND A^/� /� /y(/ Is the water over the tank? <br /> WATER Depth to the water table from grade A "ko d ce ❑Yes lJ No <br /> 8. FILL-UP Tanks to be filledlL�L hr. �f Date Arranged by kei 1 ReKe p <br /> Name Telephone <br /> ARRANGEMENTS Extra product t '70 olf'and run tank tester. How and who to provide? Consider NO Lead. <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 n <br /> 10. OTHER t h�P �P 5 0 K Vl m f r li t d Q Pl 1.1 <br /> INFORMATION tic �eac R <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 D, PETRO TITE ❑ P ❑ QUICK CHECK 2000 <br /> 11 a. TEST RESULTS Tests were made on the above tank s accordance oe <br /> with test produ d for <br /> as detailed ontest charts with results as.follows: <br /> lght <br /> Tank Identification Net Volume Change Per Hour Date Tested <br /> C' OD <br /> A OIL <br /> 12. SENSOR -t3. CONTRACTOR CERTIFIC _ <br /> CERTIFICATION <br /> 6_.;x—`,/ Technicians AFFORDA TEST <br /> Date 'Y'm <br /> 63/ N0. 2 04143 T H 0 R N T 0 N,C A. 95i86 Testing Contractor or pany. By: Signature <br /> Serial No.of Thermal Certification s <br /> Sensor C <br /> Si a Address <br /> PN6827 <br />