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AChart for Tank Syster'i"fightness Test <br /> JUN 61��1 <br /> PLEASE PRINT a <br /> 1. OWNER PropeneNa1�lJ �Vd{ Tl^ �(Ay. FS �HSD{9 <br /> Na Address Zip Representative Telephone <br /> Tank(s) -- <br /> Name Address Zip Representative Telephone <br /> got Y,7 f <br /> 2. OPERATOR Nam¢ Address Zip Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> � r <br /> 4. WHO REQUESTED Pon MA!50v3 AHb),�k2Lr&S ?re_o�er' il ro 0 6-as - <br /> Name Title IpanY or Aliilutton Dote <br /> TEST AND WHEN 6 o /Ati 9A-3;* X09 -$3!o-111,0- 0 <br /> Addr ^�� Zip Telephone <br /> Identify by Direction Capacity Brand/Supplier GradeApprox.Age Steel/Fiberglass <br /> 5. TANK INVOLVED Faat�otn _LAX eeel <br /> 6C77 73 <br /> use additional lines <br /> for manifolded tanks -- <br /> Location Dover Fills Vents Siphones Pump. <br /> 6. INSTALLATION too tri hCe Pro ricf P H 9 �vrHO� P <br /> DATA FoiI A10AHoof Ifaii-1'h <br /> North inside driveway. Concrete,Black Top, Sixe.Rtehll make.Drop Suction,Remote, <br /> Rear of Orion.etc. Earth.etc. tubes.Remote Fills Sixe,Manlfolded Which tanks? Make it known <br /> 7. UNDERGROUND Is <br /> me water over the lank? <br /> ,�D y.l� t <br /> WATER Depth to the water table from grade A O'" ` ❑yes No <br /> Tanks to be finta� <br /> ed�hr j6_1V/9/ Data Arranged by po h yf'/asorr <br /> B. FILL-UP Name TeMphone <br /> ARRANGEMENTS Extra product to 'top off"and run tank tester How and who to provide? Consider NO Lead <br /> oa T-c S File lr__ <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Not Telephone <br /> 9. CONTRACTOR, -- — -- <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials or others to be advised when testing is in progress or completed.Visitors or observers present during test On. <br /> 11. TEST METHOD ® PETRO TITE r ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Tests were made on the above lank systems In accordance with test procedures prescribed for <br /> 11 a. TEST RESULTS as detailed on attached test chains with results as follows: <br /> Tank ldentiliceli¢n Tight NO Volume Change Per How Date Tested <br /> 6-K q8s, Eayst are <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION AFFORDA - TE$T <br /> CERTIFICATION 812 0 STREET <br /> Tachnictans OA LT.C A.95 F 3' <br /> Dale <br /> ✓] - Testing Conveptor or Company. By'. Signature <br /> Serial No�Tnermoi Caitiff tlonI f4y9Z>7 <br /> Sensor Address <br /> q1-�t <br /> . _ y3_ - <br /> codification N PN6827 <br />