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TANK INSTALLATION CHECKLIST <br /> t <br /> TO INSTALLER : After tank installation, deliver the Installation Manualwith the completed Tank Installation Checklist to the tank owner. Retain a copy ofo <br /> each for your records. <br /> TO OWNER : After installation, retain the limited warranty, the Installation Manual and completed Tank Installation Checklist for future reference and to <br /> facilitate any warranty claim. <br /> INSTALLATION DATE(S ) : _I A71V J PERSON COMPLETING FORM : �401e SX a�iV.r .' <br /> vINSTALLATION ADDRESS. 4, 6tC eC�6�oeA—(1 ! �,'b�__ _7 �6 <br /> " t . :h <br /> itibTlQ A K ?t. k i2.` '•rte t f <br /> ;TANK # <br /> V x c <br /> Tank type - Sing le-Wall (SW), Double•Wall ( DW) D4) 040 D60 <br /> Tank Usage ( Fuel) — Fuel, DEF; Pipellne•Sumfr -� <br /> Tank Usage (Water) — Potable Water, Water Collection <br /> Tank Usage {Wastewater) —. Grease fnterceptor,Septic,. Industrial Waste <br /> water/Chemical All* W10 <br /> Tank Usage (Oil/Water Separator) <br /> N <br /> Nominal Tank Diameter — give in feet / r <br /> Nominal Tank Capacity — give in gallons or, liters (and note .which) IAN 000 <br /> If applicable, ULIULC # ( read from tank label ) Vs or no �- jy�, S 22,E 13- 1y3 2 <br /> , , .? .: <br /> .. . . ,., f q. <br /> SITZ t�dFDI MATIOf� {Sie Se ion, 1 , � . . TAI �C #1 y, f } TANK 2 ,.. n � IAi ISS# �4 � ` <br /> Primary backfill meets Appendix C requirements yes or no 14 5 <br /> Secondary backfill material will be used -- yes or no m <br /> Secondary backfill meets our requirements yes or no Sys <br /> Geotextile will be used - yes or no <br /> I <br /> Excavation - shored or not shored ro <br /> Tank will see traffic loads ( H2O or HS20) - yesor no. �t <br /> Holecondition - dryorwet <br /> Anchoring system will be used yes or no <br /> If applicable, anchoring system used - deadmen or anchor slab <br /> Ivacuum <br /> L ! � p' : AtaV� f` •.It , r�i"'V s 14 # q ,.,",: ,• : , , >1 : NK#2i:� ,te :�i. } : \ 3 . • ,44 -Shipping damage - yes or no <br /> Loss•: of vacuum - yesornoMonitoring fluidvisibleon interior of tank - yes or no A/Monitoring fluid visible on exto!grof tank - yes:ornoenv <br /> rements met for double-wall tanks shipped under interstitial- yes or no . If yes , record the value . /ir /V//f <br /> Record fluid level in reservnir. fordo ub (e wall wet tanits ,r' �`If required , tank passed pressurelsoap .test - yes or no5 '" <br /> Z CAL I X E R X E S' IMOG1119PP 37 <br />