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Dfa Chart f®r Tank SystetTightness Test <br /> JUN, 43f `v <br /> PLEASE PRINT ENVIRONMENTAL HEALTH <br /> 1. OWNER Property L7 <br /> Neme Addmss Zip Reprasenmtive Telephone <br /> ankfsl� <br /> Name Address Zip Representative Telephone <br /> 2. OPERATORGary" <br /> Name Address Zip Telephone <br /> 3. REASON FOR <br /> TEST _ _- <br /> (Explain Fully) <br /> 4. WHO REQUESTED �Oh LYSD/?�sip�l�Wm� (red. Yr PA4 0_� T_Mftsq If <br /> TEST AND WHEN Nam�DTcTIN Co1nyorAffiliation Of .71D _ Dal-Y^^ <br /> A ss Zip Telephone Ox-(/ <br /> identify by Direction Capacity r6_d/SupphtGrade Approx.Age Steel/Fibargiess <br /> 5. TANKINVOLVED LA {i <br /> Use additional Imes <br /> for manifolded tanks <br /> Location Cover Vents Sipho^es Pa�p. <br /> 6. INSTALLATION �py�y B� �o+1arC� aAlf O�eY"Ofie <br /> DATA <br /> 'C"'a I Cs lan� �a rt �t <br /> North Inside driveway, Concrete.Black Top, Six.,Tilellll make,Drop Suction,Remote, <br /> Rear of station,etc. Earthetc tubes.Remote Fills Sub.M.mblded Which tanks? Make II known <br /> 7. UNDERGROUNDQ Is the water over the tank? <br /> WATER Depth to the watertable from grade II I,/a D n { [�Q F ❑yes WNo <br /> Tanks to be filled N _.� �JJ Data Arranged l y <br /> 8. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off'and run tank tester. How and who to provtae+ Consider NO Lead. <br /> Terminal or Omer contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved - <br /> 10. OTHER — -- --- <br /> INFORMATION --.. <br /> OR REMARKS __ - — — - <br /> ove.Othemis or others to be advised when tesfing is in progress or completed.Visitors or observers present during test,etc <br /> etc <br /> Additional information information on any items ab . <br /> 11. TEST METHOD ® PETRO TITE 2P ❑ PETRO COMP El QUICK CHECK 2000 <br /> Tests were made on the above tank systems In accordance with test procedures prescribed for <br /> Ila. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Net Volume Change Per Hour Dale Tested <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> AFPoi;u�. - rsr <br /> CERTIFICATION <br /> Tech n pian 812 C S'�R E�;E'i <br /> t5—a —ter/ car rLA 964 <br /> Date t. ` - <br /> 4&gTb.iContrectororCompany. By: SlpnaWra <br /> Serie)No.of Thermal Candlestick,a •/"Z �/��� <br /> Sensor <br /> 9/—//}i'3 Adtlress <br /> Certification a PN6827 <br />