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APPENDIX E <br />Tank, Installation Checklist <br />TO INSTALLER: After tank installation, deliver the Installation Manual with the completed Tank Installation Checklist to the tank owner. Retain a copy <br />of each for your records. <br />TO OWNER: After installation, retain the limited warranty, the Installation Manual and completed Tank Installation Checklist for future reference and to <br />facilitate any warranty claim. <br />INSTALLATION DATE(S): PERSON COMPLETING FORM: [ZA F-PFL o S <br />INSTALLATION ADDRESS: 120 5 _ t e^4e,— J -F . 51-o k=4 o., r C R- 95-202— <br />TANKINFORMATION <br />.rTANK#7 <br />des <br />TAT�1K#� <br />��LS <br />t� STANK#3'�� <br />y$5 <br />;TAf�K#4 ``�' <br />Tank type -Single -Wall (SW), Double -Wall (DW) <br />p <br />GS <br />e5 <br />Tank Usage (Fuel) -Fuel, DEF, Pipeline Sump <br />c(t5 <br />FVLI qt <br />D1e.- <br />Tank Usage (Water) -Potable Water, Water Collection <br />N/A <br />Nz} <br />N H <br />Tank Usage (Wastewater) -Grease Interceptor, Septic, <br />Industrial WastewaterlChemical <br />P/4 <br />/V/14 <br />ka-red <br />Tank Usage (Oil/Water Separator) <br />,Vl9 <br />Nyq- <br />N <br />_ <br />Nominal Tank Diameter -give infect <br />Inl <br />/bl <br />to r <br />Nominal Tank Capacity -give in gallons or liters(and notewhich) <br />20;0ob_ <br />(6DOO <br />12r,000 <br />If applicable,ULIULC#(read from tank label)-yesorno <br />g-1tixy <br />3-1431ybc)l <br />B-14"'40'{04 <br />` � 31TEINFORMATIUN(See,settion7) � <br />Primary backfill meets AppendixCrequirements-yesorno <br />.rTANK#7 <br />des <br />TAT�1K#� <br />��LS <br />t� STANK#3'�� <br />y$5 <br />;TAf�K#4 ``�' <br />Secondary backfill material will beused-yes orno <br />s(t`v. <br />GS <br />e5 <br />Secondary backfill meets our requirements -yes or no <br />c(t5 <br />C5 <br />eS <br />Geotextile will be used-yesor no <br />Excavation -shored or not shored <br />5(U �� <br />L�nu re <br />ka-red <br />Tank will see traffic loads (H20 or HS20)-yes or no <br />,#-,b <br />lei <br />`{t5 <br />_ <br />Hole condition -dry or wet <br />n0 <br />9r <br />r <br />Anchoring system will be used -yes or no <br />r S <br />1{t 5 <br />If applicable, anchoring system used-deadmenor anchor slab <br />)(OrdMAn <br />DdAJrvtan <br />9t,%JYAAh <br />STACLATIONINSPE�TIOShipping <br />damage -yes or <br />o <br />v\.n <br />hc) <br />Loss ofvacuum-yesorno <br />I <br />n <br />V\ <br />t: <br />Monitoring fluid visible on interior of tank -yes or no <br />,#-,b <br />Yn o <br />tn6 <br />_ <br />Monitoring fluid visible on exterior of tank -yes or no <br />n0 <br />ilbi <br />F <br />Requirements met for double-wall tanks shipped under interstitial <br />�`vc <br />rllYr <br />vacuum -yes or no <br />1 <br />N <br />Record fluid level in reservoir for double-wall wettanks <br />lH " <br />3 Y - <br />' rf a <br />If required, tank passed pressure/soap test-yesorno <br />NA <br />N A <br />PTA <br />Continued on Next Page <br />Z��� XERXES APPENDIX E 45 <br />