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DO Chart-for Tank Syste0 ightness Test <br /> JU; <br /> ENVIRONMENTAL HEALTH <br /> PLEASE PRINT <br /> � /� Rif"18 i9 209- <br /> 1. OWNER Property I \Yr }�(�y �0 —M0,j B1V;A I rae� ? , u`z2k �-209ASon g yze <br /> n Na S A— ddress— —�hZiP Representative Telephone <br /> Tankls)kV <br /> Name Address Zip Representative Telephone <br /> 2. OPERATOR 6d ✓+� <br /> Name Address Zip Telephone <br /> 3. REASON FOR 0411 n u�/ - <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED F11�CI� 4�n P� b�fe Lt�ofKS bkr cf�r CCb, fJ�28�9/ <br /> TEST AND WHEN "°m° Title Co nyorAHlllatlon <br /> F011 13) 101 Ty'0C Ad s Zip Telephone_! <br /> Identify by Direction Capacity &end/Supplier Orad. Approx Age Steel/Fiberglass <br /> 5. TANK INVOLVED rot pt 1- <br /> Use additional Inas <br /> --- — — — — — <br /> for manifolded tanks -- --- <br /> Location Cover Fills Vents Siphons Pumps <br /> 6. INSTALLATION 10l �flqz <br /> DATA reel j�,�andQr Qpa ll <br /> North inside driveway. Concrete.Black Top, Size,Thehll make,Drop Suction,Remote. <br /> Rear of station,etc. Earth,etc tubes.Remote Fills Size,Manilolded Which tanks? Make if known <br /> 7. UNDERGROUND p Is the water over the tank? <br /> WATER Depth to the water table from grade 1�/„ �� L 1 1Y. �No <br /> 8. FILL-UP Tanks to be hfIad�dbQ hr _6/ LDate Arranged by �OI7 IT1tY 4B�7 _ __ <br /> theme Telephone <br /> ARRANGEMENTS Extra product to"top off'and run lank tester. How and who to previdap Consider NO Lead. <br /> -- <br /> Terminal or other contact <br /> Inc notice or inquiry <br /> Company Name Telepnona <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved -- <br /> 10. OTHER <br /> INFORMATION - - - — <br /> OR REMARKS _ --- - -- -- --- <br /> Additional IMormahon on any items above.011lcials or ote <br /> thers to be ativiead when sting is in progor ress campleted.Visitors or observers present during test,elo. <br /> 11. TEST METHOD 51 PETRO TITE ]_ ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Tests were made on the above tank syalemS In accordance with teat procedures prescribed for <br /> 11a. TEST RESULTS as detailed on attached lest charts with results as follows: <br /> Tank Identification Tight Net Volume Change Per Hour Date Tested <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> AFFORDA - TE$T <br /> CERTIFICATION TeahW en w 812 C STREET <br /> S_ �Date� / y+ ' A�u�tJ GALT.CA. 95832 <br /> 63 Contractor or Company. By. Signature <br /> Serial No.of Thermal Cenilicallan k �/� V /� ��" <br /> Sensor <br /> s �/ �� Address <br /> Certification a PN6827 <br />