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Data Chart for Tank System Tightness Test <br /> exit <br /> PLEASE PRINT <br /> 1. OWNER Property aif E61r-1`1 16,1 or of 7P 13 01^1 <br /> Name ,I'� d s Zi"pr,,... � n r gy t�tlye i_,�(�ry 'T' Telephone <br /> Tank is)❑ �1/ �' t hOl Y34'F Lrayl J... J-f�k� r�7 F �-!I'.-:I <br /> 9 <br /> 11 I <br /> Name .--+ Address Zip L N P11 149*11*1044Telephone <br /> 2. OPERATOR CHP 333 k)O ®e <br /> Name Add(As Zip Telephone <br /> 3. REASON FOR 12,7oitgl 7--,(,?5 <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED a� In,, Keel Ca/ mr-h to n I ttk_w 4 �gI <br /> TEST AND WHENName Titl Company or Affiliation Date <br /> ER , 9cfi—w0� <br /> Address Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED 000 IPL9ra <br /> Use additional lines <br /> for manifolded tanks <br /> Location Cover Fills VentsSiphones Pumps <br /> 6. INSTALLATION a -`"/f,/ 0-0y)arleb- J f/ air (11 <br /> DATA zelc<hol <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, I✓�1 /T rt Is the water over the tank? <br /> WATER Depth to the water table from grade �1�©-N Y �+ �` r1 on ,/ ❑yes No <br /> Tanks to be filled hr._1__�L-Date Arranged by <br /> 8. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to'lop off'and run tank tester. How and who to provide? Consider NO Lflad. <br /> r O�to p w <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 -<Y1U <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 TITE ❑ 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 as detailed on attached test charts with results as.follows: <br /> Tank Identification Tight Net Volume Charge Per Hour Date Tested <br /> a K RU? k r-eqP, Ps <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> CERTIFICATION <br /> Technicians , //1 r <br /> Date <br /> AFFORD - -'C/.//./ <br /> V 3/ 8120 Vpp ftnr Wr or Company. By:d4nature <br /> Serial No.of Thermal Certification M GALT CA 95632 <br /> Sensor <br /> Address <br /> Certification s PN6827 <br />