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V * a 0 <br /> Data Chart for Tank System Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER PropBrty(}� �°/T a/' SZ2C G<' 0 /�/C9S®S.L/N�xlt! 9 le I-AxleY rA <br /> Tanks)® Name Address Zip Representative Telephone <br /> Name Address Zip Representative Telephone <br /> 2. OPERATOR All c4AJ1 C43M yto re P " -//00 <br /> Name Address Zip Telephone <br /> 3. REASON FOR T" <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED eST 'C N C U E lo' <br /> TEST AND WHEN Name Title company or Affiliation Date <br /> Address Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED <br /> Use additional lines <br /> for manifolded tanks <br /> Location Cover Fills Vents Siphons$ Pumps <br /> 6. INSTALLATION g799T 01= <br /> DATA /.ot/t_aorvi* eA_NC4e 4f �° Z �� IVOANL® S44G770J`J <br /> North inside driveway. Concrete.Black Top, Size,Titefilt make,Drop Suction.Remote, <br /> Rear of station,etc. Earm,etc. tubes.Remote Fills Size.Manifolded which tanks? Make If known <br /> 7. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the water table from grade ,p ('J' ) ❑tYea ❑N o '' J <br /> $. PILE-UP Tanks to be filled hr. ` �v Date Arranged by t®.• / 4qSG il1/1U/s 144 Y Name Telephone i�f <br /> ARRANGEMENTS Extra product to-top off"and run tank tester. tow and who to provide? nsider NO Lead. <br /> Terminal or other cantacy9/,,,,g,, c <br /> for notice or inquiry C:. ® 7 0/_ J <br /> Company Name - Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> r <br /> 10. OTHER <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 orbbsarfe[s present du"Ping test,etc. <br /> 11. TEST METHOD PETRO TITS ElPETRO COMP ❑ QUICK CHEC� "K­2' <br /> 000 <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for <br /> 11 a. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification + Tight Leakage Indicated Date Tested <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> CERTIFICATION <br /> `7 ,n® Technicians <br /> Date <br /> :5� Testing Contractor or Company. By: Signature <br /> Serial No.of Thermal Certification e �� !C// <br /> Sensor `." ' ! 7L' / ��CZX A r6C 1, ►K,/ <br /> 2. /� �/G 91- �d�3 Address <br /> Certification p <br /> �. PN6e27 <br />