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APPENDIX E <br />TO INSTALLER ,t . ,. I <br />.. • . 1._ A .I.� . .. .' , ir�r• I:;r �.;;nu� i�F•1, , �i,G <br />TO OWNER nt', In In,LiILI „I' n .•i ,l <br />1. 1r' w, „�n C� <br />INSTALLATION DATEISI , Ovu 11 4 7'o I? PERSON COMPLETING FORM: Lc, V,-;, <br />INSTALLATION ADDRESS: (p()r)9 NI,.44� �_ f 7-11 - r S tb L 41 <br />4 W1 <br />TANK INFORMATION <br />L i <br />L1,2s - <br />_ y;-5 - <br />TANK #1 <br />TANK 92 <br />TANK #2. j <br />I0 l� <br />N 0ofvacuum-yes <br />or nopj <br />Tan1 Usage (Fuel) -Fuel, DEF, Pipeline Sump <br />Fu z <br />IF <br />fluid visible on interior of tank -yes or no <br />7. rlk Usage (Water) -Potable Watpt Water Collection <br />Nib <br />Nle <br />N/A <br />Tank Usage (Wastewater) -Grease Interceptor, Septic, <br />jJ a <br />N p <br />Industrial WastewateriChemical <br />N/A j <br />N /JA <br />, /A- <br />VIA - <br />Tank <br />Tank Usage (OilVater Separator) <br />NtR <br />Nominal Tank Diameter -give in feet <br />Nominal Tank Capacity -give in gallons or liters (and note which)( <br />25,OCu <br />12Coo <br />G <br />�.ec <br />If applicable, UUULC # (read from tank label) -yes or no <br />(y 3iJ �lO�i S <br />13 I 34:3b�j <br />517E INFORMATION (See section 1) <br />Primary backfill meets Appendix C requirements -yes or no <br />Secondary backfill material will be used -yes or no <br />Secondary backfill meets our requirements -yes or no <br />Geotextile will be used -yes or no <br />Excavation -shored or not shored <br />Tank will see traffic loads (H20 or HS20)-yes or no <br />Hole condition -dry or wet <br />system will be used -yes or no <br />It aonlicable anrhnrinn tvstam usarl-dP;,.dman nr anrhnr clah <br />TANK #1 <br />TANK #2 TANK #,,F <br />L1,2s - <br />_ y;-5 - <br />TANK #2a <br />N0 <br />�jk <br />I0 l� <br />N 0ofvacuum-yes <br />or nopj <br />j <br />Nf /kitoring <br />fluid visible on interior of tank -yes or no <br />z <br />�5 <br />itoring fluid visible on exterior of tank -yes or no — <br />�jb <br />PREINL <br />LATION INSPECTION AND TESTING (See sections 3 and 4) <br />TANK r 1 <br />TANK #2a <br />TANK #3.E <br />ping damage -yes or no <br />N 0ofvacuum-yes <br />or nopj <br />j <br />Nf /kitoring <br />fluid visible on interior of tank -yes or no <br />D <br />NJ D <br />itoring fluid visible on exterior of tank -yes or no — <br />�jb <br />jJ a <br />N p <br />Requirements met for double-wall tanks shipped under interstitial r <br />vacuum—yes or no k) <br />Record fluid level in reservoir for double-wall wet tanks _ ) 'r <br />If required, tank passed pressure/soap test -yes or no ye y U S yY S <br />ZCL XE <br />TANK #4 <br />TANK #4 <br />TANK #4 <br />VS' <br />45 <br />Scanned by CamScanner <br />1 <br />