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OF 0 <br /> Data Chart for Tank System Tightness Test ` <br /> PLEASE PRINT <br /> 1.-OWNER 1,Property.I®�. (/j'� G/"' rj,°V d,/eApt.j /ZIGS� S,L e NG1CrLl 4.r.&06 fE Y&.r1_-Z149 <br /> Tanks) Name Address Zip Representative Telephone <br /> Name Address Zip Representative Telephone <br /> �. rd® <br /> 2. OPERATOR Name Address Zip Telephone <br /> 3. REASON FOR Nhflli _ '1'Z�ST <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED rz 4e.&,z7— <br /> TEST AND WHEN Marne Title company or Affiliation Date <br /> Address Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglaw <br /> 5. TANK INVOLVED <br /> ®190 YAAe 0Ai4 <br /> Use additional lines <br /> for manifoided tanks <br /> Location Cover Fills Vents Siphons Pumps <br /> 6. INSTALLATION a,74 Sr 47r- <br /> DATA / 44e Al s �UdNL►- Gt CTIOA <br /> North inside driveway. Concrete.Black Top, Size.Titefill make.Drop Suction.Remote. <br /> Rear of station,etc. Earth.etc. tubes.Remote Fills Size.Mandokfed Which tanks? Make H known <br /> 7. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the water taws from grade u / /❑res W No <br /> 8. FILL-UP Tanks to be filled /600 hr. 6—/�an. ate Arranged by� 4&' TelephoneNam <br /> ARRANGEMENTS Extra product to~top off'and run tank tester. Now and who to provide? Consider NO Lead. <br /> Miao_l C <br /> Terminal or other contact/I 7 lJ®��e t/ t"�•k 2 /�' /®�Q <br /> for notice or inquiry LL.. // T7 <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 o"I's"rvara-present;tring-t8st'etc. <br /> 11. TEST METHODPETRO TITS ❑ PETRO COMP El M%jQUICK 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 Leakage Indicated Date Tested <br /> t ®dp f <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> CERTIFICATION <br /> i9- /Q Technicians,�r 1 � <br /> Date i. W sC=A1AJ4f�6.-�'� ,t/ ®Pf�" :_�si../c-. �.l (7.Ll.h .�ae•.,...Ct.^ ': <br /> /4♦f�� Testing contractor or Company. y: Signature <br /> Serial No.of <br /> TTiheerrmal Certification.« �R'<�Irl Y D�® J..®�'�^ � .�.,. <br /> Sensor / `z' .� T�`� <br /> 2 �r s1 /rG, •�, �I'�a�y Address <br /> Certification a PN6827 <br />