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0 0 <br /> Data Chart forTightness <br /> PLEASE PRINT <br /> 1. OWNER Property f� /T oto /J 02 &Zer s4m c ea 9y Q' <br /> Tank(s) Name ® Address Representative Telephone <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR wtv id P9 L 7r_57 T' <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED Fr A, 11.-T 1'92A r: 4y DX <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED _off �J n —c LU Nk CA b <br /> Use additional lines <br /> for menlfolded tanks 1 <br /> bJ T 0/a <br /> Location Cover Fills Vents Siphons Pumps <br /> 6. INSTALLATION 54) <br /> UTN Or A�, y�i <br /> �e <br /> DATA /6u.r j-a►..�4s .Z <br /> North inside driveway, Concrete,Black Top, Size,Titeffll make.Drop Suction,Remote. <br /> Rear of station,etc. Earth,etc. tubes,Remote Fills Size,Manifolded Which tanks? Make if known <br /> 7. UNDERGROUND le the water oder the tank? <br /> WATER Depth to.the Water table / ❑Yes X No <br /> 8. FILL-UP Tanks to be filled/ hr. �•/�' Date Arranged by 501 ' /�`,q 4/4/6t e/9 %yam e'd <br /> , <br /> Name Telephone <br /> ARRANGEMENTS Extra product to'lop off'and run tank tester. How and who to provide? Consider NO Lead. <br /> tcl. /.3uf!� <br /> Terminal or other contact _ y 40 <br /> for notice or inQufry ®T � ® �®�� BW ®i qr u T „� 4/6 / J0f i/ <br /> Company Name Telephone <br /> 9. CONTRACTOR, ^' s <br /> MECHANICS, o L .► _ <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 of observers present during test.etc. <br /> Tests were made on the above tank systems in accordance with test procackAres prescribild for <br /> 11. TEST RESULTS as detailed on attached tact charts with resuft as follows: <br /> Tank Identification Tight Leakage Indicated pate Tested <br /> a200(X -4 Yes AOXII,Z.% /709 <br /> 12. SENSOR 13.This is to certny that Nlpe tar*syswns was tested on the dates)Witown.Those Inckded as 1W meet 1M editerb sistabils1iied by the <br /> CERTIFICATION National Pin Protection Ist 32&y_ 1.3_F 9 / Technicians st e� /� 'J /'� <br /> Data u„�, If".LYv�2L� Vo/T 7" ®/� � k® <br /> e t' Testing Contractor or Compony, By: Blgriabue <br /> Serial No.of Thermal Certlflcatfon;:�®y ®7® � ���c � A,ry <br /> Se* IC0T <br /> Adtkess <br /> 2 <br /> Certification If PN6827 <br />