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it <br />PLEASE PRINT /0 0 96 3 <br />Data Chart for Tank SyAm Tightness Test <br />1. <br />OWNER Proper) ❑ <br />I� <br />Tank tel CEJ <br />%- - = 5 C—rcV <br />Name Address Representative <br />Telephone <br />r*S <br />Name Add. Representative <br />Telephoh ' <br />2. <br />OPERATOR <br />Name Address <br />Telephone <br />3. <br />REASON FOR <br />TEST <br />!Explain Fully) <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Name TWe Company or Affiliation <br />Deter <br />Address <br />Telephone <br />5. <br />TANK INVOLVED <br />Ude additional line <br />for manlf(Dlded tanks <br />Identify by Direction capacity <br />Brend1iupplier Grade Appro.. Age <br />�t Sc' moi\ <br />S1�lFlberpless <br />GEr_nc _ lT on <br />r <br />6. <br />INSTALLATION <br />DATA <br />-- <br />- <br />Location Cover <br />Cor✓er-Gm- <br />- <br />With Inside driveway. Concrete, Black Top, <br />Rear of station, Mc. Earth: Cc. <br />Fills Vents Sipm. <br />cr, t!4E <br />Size, Ttefill make. Drop <br />tubes. Remote fills Size, Mendoldad Which tanks? <br />Pump. <br />f ceT(� <br />Suction. Remota. <br />Make if known <br />7. <br />UNDERGROUND <br />WATER <br />1s the water over the tank? <br />Depth to me Water tame O ❑ ye ❑ No <br />8. <br />FILL -UP <br />ARRANGEMENTS <br />- - <br />- - - <br />Tanks to be filled hr. Date Aringedb <br />Name <br />Ekaa product to lop off' and run tank tenter. How and who to provide? Consider NO Leen <br />Telephone <br />Terminal or onwr contact - <br />for notice or inquiry - - <br />Company Name <br />Telephone <br />9. <br />.. - <br />CONTRACTOR, <br />MECHANICS, <br />any Other contractor- <br />ineolved <br />_ <br />10. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />Pi✓ i Fc `t) -n Ze 57 - t -r- i ��� n �Erc 7--,Le -gi-g-_ i <br />Admtlonel Inlormation on any Items above. Officials or othms to be advised when testing is in progress or completed. Visdo a or <br />observers present during had. etc. <br />11. <br />TEST RESULTS <br />Tests were made on the above tank systema In accordance with teat procedures prescribed for <br />as detailed on attached test charts with results a, fonows: <br />.Tank IdemiOceuon Tight Leakage Indicated <br />Date Tested - - - <br />12. <br />SENSOR <br />CERTIFICATION <br />13. This is to unify that these tank systems ware bated on the date(s) shown. Those Indicated as'Tighr <br />t+aB nd FlnPmte7 Aeodallon Pamphlet 328. <br />Technida <br />� A <br />Testing Contractor or Company. By: <br />Certification ff <br />meet the attend established by the <br />Signature <br />Date <br />`Barrel <br />el of Thermal <br />Addreas <br />2 <br />Cadlacatlon a P146827 <br />I <br />IL . <br />