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o <br /> Data Chart for Tank System Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER Property LLF C/! 7 ot47 57Uc.e.m,J 11(05 $.GiryGcf4tJ gs.-kw S Y `as <br /> Tanks)® Name Address Zip Representative Telephone <br /> Name Address Zip Representative Telephone <br /> 2. OPERATOR •L/e 'f�'E' <br /> Name Address Zip Telephone <br /> 3. REASON FOR N 9fr4(_ 7P-57— <br /> TEST <br /> TTEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED A i T° - " <br /> TEST AND WHEN ".a"'e Title company or Affiliation Date <br /> Address Zip Telephone <br /> Identify by Direction capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED <br /> ups /"4 / 000- / -L <br /> Use sdditional linea — <br /> for manffolded tanks <br /> Location cover Fills Vents Siphons Pumps <br /> 6. INSTALLATION 11=.$ <br /> -)'jDATA A <br /> NO msf driveway, Concrete,Black Top, Size,Titefiil make,Drop Suction,Remote. <br /> Rear of station,etc. Earth,etc. tuba,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 U�jN `A /, ❑ RMY. R <br /> Tanks to be filled Lehr. ` ° p Date Arranged byv- "r• ZA& <br /> 8. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"lop off"and run tank tater. How and who to provide? Consider NO Lead. <br /> Terminal or other ainntaC{/)/r y n`V s leru pi —se <br /> /r w, 1-16.2-//00 for notice orrnquiry fs _ 7 u LA/•i G <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 any items above.Officials or others to be advised when testing is in progress or completed.Visitors or observ4rs�tduringtest(itcr., <br /> f,s, <br /> 11. TEST METHOD 12 PETRO TITS =E1 PETRO COMP ❑ QUICK CHECK 2000 £ <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 Idennttif^ication Tight Leakage Indicated Date Tested <br /> 0000 00 <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> CERTIFICATION <br /> e7® Technicians <br /> Date i.�.Gtil. '� $&rAJ/"(d <br /> Testing Contractor or Company. By: Signature <br /> Serial No.of Thermal Certification a <br /> Sensor /��^., <br /> 2 dA. .�.Ir:' 7!®fC?/� --- Address <br /> Certification• <br /> PN6827 <br />