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0 <br /> Data Chart for Tank System Tightness Test <br /> PLEASE PRINT hECF1VED_-1/ " - <br /> 1. OWNER Property❑ 1,4eez _zr I I'1 1 g <br /> Name / : Address Representative �--{f�1 <br /> -" Telephone <br /> Tanks)1:1 <br /> Name Address p e i e hone <br /> 2. OPERATOR 17xj, GC> <br /> Name Address Telephone <br /> 3. REASON FOR r <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN arae Title Company or Affiliation Date <br /> Address Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx-Age Steel'Fiberglass <br /> 5. TANK INVOLVED <br /> Use additional lines <br /> for manifolded tanks — <br /> 1-04ion Cover Fills Vents Siphones Pu <br /> 6. DATA INSTALLATION ���/ D/— ��, lG' �/� /� � -l�fa'j� <br /> North inside driveway, Concrete.Black Top, Size,Titefill make,Drop Suction.Remote. <br /> Rear of station,etc. Earth,etc. tubes.Remote Fills Size,Manifolded Which tanks? Make if known <br /> 7. UNDERGROUND l LL// /Gem Is the water overthetank?LTJ <br /> WATER Depth to the water to `� I ' ❑Yes No <br /> 8. FILL UP Tanks to be filled fir. Date Arranged by <br /> Name Telephone <br /> ARRANGEMENTS Extra product to'lop off'and run tank tester. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry !ll���✓✓✓ !tip <br /> Company Nam Telephone <br /> 9. CONTRACTOR, -J <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,etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> 12. SENSOR NMI 131 a ystems wa"asted on the date(s)shown.Those Indicated as'Tight"meet the criteria establl by the <br /> CER/!TTIFICAATIO = a�Of1 pam 329L <br /> —61 <br /> Date 1 <br /> Testing Contractor or Company. By: Spnature <br /> Serial No.of Thermal— Carti}icadon tl TRIANGLE INC. OF SACPAMEM <br /> Sensor <br /> Address <br /> 2. &ACRAAAEM .CAL.IfORNIA M23 <br /> Certification a PN6827 <br />