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Data Chart for Tank System Tightness Test <br />noN ' <br />LEASE PRINKSTA_ � v D�� <br />I. OWNER op"[j <br />Tw*ts) ❑ Nrre Address ReprgantetM Telephone <br />Warne Address RapmenWiva Telephone <br />2. OPERATOR <br />3. REASON FOR <br />Henna Address <br />Telephone <br />I TEST <br />17 9 <br />% <br />Fwiyt <br />4. WHO REQUESTED <br />TEST AND WHEN <br />e Title Company or A"action <br />Date <br />Address <br />Tewpnone <br />5. TANK INVOLVED <br />Idem", by okectlon <br />capacity <br />erand/Supp&w <br />Apo-.. Aye <br />StnrM/Rbwpleas . <br />` <br />_ Use additional anas <br />for <br />nw*k*dW faiths <br />JF <br />_ <br />`� '- INSTALLATION-. <br />DATA <br />LOCr10" - <br />r <br />� Nom kehL Arf i v <br />Raw d alatbrl atc <br />.tow <br />Cono eW Hack T <br />Ew1R Mc <br />FiMa <br />Sire. T"e"e mala. Orop <br />hlbea. Rannoha Fits <br />1/wlb <br />SW. ManNbldaA <br />Steve <br />WIW31 taNnT <br />Pumps <br />Salctwl% Rahaolal <br />Matra ■ Wlolwt <br />`i. UNDERGROUND <br />WATER <br />oepih to OW WHOM taws <br />bthe -.twd».the lank? <br />❑ yes 0 N <br />-FILL-UP <br />ARRANGEMENTS <br />Taltlla ho w NOWeH. Dr.. w Nene <br />Eafe s e"m to 1ep eer wo w* ww. ttow anA a+o ho Conreidar NO toad `- <br />Talapllorr <br />- <br />ir <br />Twwnd a over oorrtact <br />for nolloa or hrpuiry <br />- <br />Cornparry Name <br />Telephone <br />':.CONTRACTOR, <br />'~ MECHANICS, <br />any other contractor <br />JLQ— tr <br />C� <br />Ymolved <br />. <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />.. <br />IMOrmaion on arty hlMu above. 0"imals or nthwa b to advraad wren Us" a w proWess or <br />. Vle0ors or obawera p(wrK dWkq laeL 44C. <br />11. TEST RESULTS <br />TAt"s Wrenn made on the about tank syste" In accordance with lest proc@dune prescrl <br />as deta"d on attached lest charts with reaft as k4ows: <br />Tank ldenWi vti Tight Leakage kxdicated <br />for <br />Data Tasted <br />12- SENSOR 13. Tw Ir b cwwy thM thee. tank oy tee wen. heated on the dA*) shown Thoea ktdcabd ae -nqW meat this «nena eatabbs ed by the <br />CERTIFICATION tonal Fire P''OMct°" Aaaoetatim Pw phWt 329. <br />. TeChkMClafla <br />Date SCom Co. <br />Taabrq Yontrac w or Company. By: spnatWH <br />serW Se dTherrcW cwt+rr�,twn. lmov 1919 MARKET Sr DA AND , (A <br />Address <br />Cerbbcatbn a PN6827 <br />