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ata Chart for Tank Systm Tightness Test <br />/mo qda <br />PLEASE PRINT �yj/i D.SEN�SJIAuR.[E. Pill <br />OWNER <br />�- SEK✓E "/ J. 60,4,ew o.l*Ralo C '7N) <br />1. property <br />Tankfq ® <br />Nemo Address 1 , <br />ale C <br />Phone , iJ <br />. <br />Nems AdOroae Representative <br />Telep^one <br />�u>) 8 d MT D3E,J X39 S SiOCtson� IQ t CA (r�o9) <br />2. OPERATOR <br />NBTe Amrees <br />T1ep" <br />3. REASON FOR <br />ArlNoey c TES <br />TEST <br />(Explain Fully) <br />M F ° 04a c L£n v/RoA)McwTAt- SVC -�-Z SER /E <br />4. WHO REQUESTED <br />'60C�MN" <br />Title Company or Afllllallon <br />e <br />Date <br />Dat <br />TEST AND WHEN <br />Name <br />Address <br />Telephone <br />Identify by Direction <br />Cape<Iry - Bramm'Suppller <br />Grace Approx. Age <br />Steel/Floarplesa <br />5. TANK INVOLVED <br />ECAaT <br />000 A - Z Su -✓L <br />- the additional lines <br />- <br />for manlfolded tanks <br />Location <br />Cover Fills <br />Vents Siphons <br />Pomp. <br />6. INSTALLATION <br />/t/oRiN_nEOOsr <br />.6%P 4-17r q/1 <br />Ric 44CpC- <br />DATA <br />S7aE <br />North hood. driyawey. <br />Concmte, Black TOP, Size, Tnefill make, Dray <br />tubes. Remote Fills <br />Size. Manlfolded -Which tanks? <br />Suction I Remote, <br />eke I known <br />Rear of station. etc. <br />Earth, std. <br />7. UNDERGROUND <br />Is the water over the tank? <br />WATER <br />Depth to the water table EJ Yet No <br />600 `� Date Artenpad by '" �AA <br />/,-7�/ <br />B. <br />Tanks to ba lilledPi b Nam <br />Telephone <br />ARRANGEMENTS <br />Extra product to 'top off 'and mnienx mslar. Now and who mprovide? rA^aider NO Lees. <br />7-ANkkP 7P,it—K <br />Terminal or other pointed $C A/g 7C <br />- - <br />for notice or inquiry Dcmpany Name <br />Telephone <br />9. CONTRACTOR, <br />MECHANICS. <br />_.. <br />any Other contractor <br />- - - - <br />swayed <br />`few <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />Additional information on any Items above. 011ldels or others to ca advised when testing Is In prrgress or completed. Visitors or obeeners present tlannB teat. MC. <br />Teat, were made on the above tank systems in accordance with lest procedures prescribed for <br />11. TEST RESULTS <br />as detailed on attached test chane with resulb as follows: <br />Tank Identification - - Tight — - Leakage Indicated - Dale Toted <br />c sr—t)0L <br />13. This is to cenfty that these tank systems were tested on the datels) shown. Thos, Indicated as'tIghr meet the cnlert, established by the <br />12. SENSOR <br />National Rm Pmtactlon Assoclabort Pamphlet 324 <br />CERTIFICATION <br />Tephnidens, / <br />La t v t, <br />Testing Coinlrador or ComDeny. By: Sgnatura <br />Date <br />=/ <br />/'Z <br />dug <br />Cerlllication it <br />Banal W. of Thermal <br />sensor <br />Address <br />Cenihzation 0 PN6527 <br />