Laserfiche WebLink
Data Chart for Tank System Tightness Test <br /> _EASE PRINT <br /> 1. OWNER Property STD-- rUr, _�� � /isl�°�T <br /> Tk(s) Name Address Representative Telephone <br /> an <br /> Name Address Representative Telephone <br /> 2. OPERATOR ---- <br /> Name Address Telephone <br /> 3. REASON FOR Lc TEST <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED /ISS 7— -G d ' 570C le,-OJ <br /> TEST AND WHEN Na Title Company or Affiliation Dace <br /> Address Telephone <br /> IdentMy by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED <br /> Lbe additional linea <br /> for manifolded tanks - <br /> Location Cover Fills Vents Siphons Pumps <br /> 6. INSTALLATION 714. a= Ce <br /> rze <br /> DATA 'StA I I-D/Au4 ®' _ /* <br /> IL.1®4ov G OT's"" <br /> Norah Inside Concrete,Black Top, Size.TIMM make,Drop Suction,Remote, <br /> PAW of station,eta Fath,eta tubas,Remote Fills Size,Manialded Which tanks? Make If known <br /> 7. UNDERGROUND Is the water over the tank? <br /> WATER Depth to ab Water <br /> It <br /> t� s ❑yes No �/ <br /> Tanks to 0e filler hr. S�� D Date Arranged by r `%'' �`'�- <br /> 8. FILL-UP Name Telephone <br /> ARRANGEMENTSrat product to ofr an d run tack tester. Flow and who to provide? Consider NO Lead. <br /> L55 6 1, dSA2n1e_ Ile k <br /> Terminal or other comae <br /> for notice or inquiry <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 observers present during test,etc. <br /> Tests were made on the above tank systerria In accordance with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> 12. SENSOR 13.Thio b to igertilly that tatted at the dabs)shown.Those Indicated as Mohr riftell the criteria estiablished by the <br /> CERTIFICATION FIM ftWOM AsdiftlaillIM ftmphkt 320` �,•.y .�/ �,� � �,r e /E ��e� <br /> 17 9 t Technicians <br /> Data rl <br /> Z;.ra....• � - <br /> ® Testing Contractor or Company. By: Signature <br /> Sandi No.of art. mal Certification 0 <br /> Sensor (I� <br /> Address <br /> 2 <br /> Certification a PN6827 <br />