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Data Chart for Tank System Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER Properly❑ f <br /> Tenkts)❑ IT. Addr se 21 Recooeda Telephone <br /> 17 10 41tvl gra vl I Lia u S �on kl z",'I C1 w °sem <br /> Name gddress — ZT Representative Telephone <br /> 2. OPERATOR 60tLn r <br /> 'Name Address Zip Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED `I'1`1 ty GVP �� <br /> TEST AND WHEN Name / Title Company or Affiliation <br /> not "1-2orale <br /> Address Zip <br /> Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED pfy L{ <br /> Little additional lines <br /> for manitolded tanks <br /> i <br /> Location Cover Fills Vents Siphons Pumps <br /> 6. INSTALLATION 1j(6) ov pYL 0 ,cL 9Y,mQ }� <br /> DATA 1 <br /> North Inside driveway, Concrete,Bleck Top, Size,Thoth make,Drop Suction,Remote, <br /> Rear of station,etc. Earth,etc. tubes,Remote Fills Size.Menllolded WM1ich tenka9 Make if known <br /> 7. UNDERGROUND (� �//t.� A I,the water over the tank? <br /> WATER Depth to the water table from gradejo0Y1e 47-e )L-r ! PC/ / Ely.. �` <br /> 8. FILL-UP Tank.to be 6llec6yblyro� <br /> S —It'//_-;2/ Data A...ngadbv I h011 Py1Ajili <br /> ARRANGEMENTS Extra product y <br /> Nemf Telephone <br /> product to'Yop oft"end Nn lank tester. [low rad who m provide? Consider NO Lead. <br /> Pr_rdii <br /> 11 <br /> b it—, <br /> Terminal or other 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 /> Additional information on any Items above.Ofhciala or oners to be advised when lasting is in progress or completed.Visitors or observers present during test,em. <br /> 11. TEST METHOD ® PETRO TITEM ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Ila. TEST RESULTS Tests were made on the above tank systems In accordance with test procedures prescribed for <br /> as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Net Volume Change Per Hour Date Tested <br /> k <br /> P © i <br /> 12. SENSOR 13. CONTRACTOR CERTIFICATION <br /> CERTIFICATION J <br /> 2—?/ hnl rte 1 <br /> p Dale Z4&;!Ot <br /> / <br /> [y V l Conhecbr or Company. By: Signet <br /> Serial No.0f Thermal Certification 1, �O 812 Q STREET <br /> Sensor <br /> 2 9,/—// • Addrme <br /> Codification x <br /> PN6627 <br />