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Data Chart for Tank System Tightness Test <br /> PLEASE PRINT n <br /> 1. OWNER Property❑ <br /> Tank(g) Na - Address Representative Telephone <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR t1" <br /> TEST <br /> (Explam Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Telephone <br /> Identity by Direction Capacity Brand/ upplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED z,2D00 INCT L <br /> Use additional lines <br /> for manifolded tanks <br /> Location Cover Fills Vents S�phones <br /> 6. INSTALLATION k?PQi C­` <br /> f <br /> DATA <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 Is the water over the tank? <br /> WATER Depth to the Water table ��' R#V``64r ❑Vas No <br /> 8 FILL-UP Tanks to be filled/� �' hr. 1 D Date Arranged by• 77Z, <br /> Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run tank tester. How and who to provide? Consider No Lead. <br /> Terminal or other contact A_-)e)14_) <br /> l 1D r, 1 <br /> for notice or inquiry //l� 1_/ <br /> Company Name Telephone <br /> 9. CONTRACTOR, t?119A_)6 L iF_ IA-) — <br /> MECHANICS, <br /> any other contractor £ / /2 /,�7_`, e C/ <br /> involved �.. -- r <br /> Gly �w/� C��v3T <br /> 10. OTHER L-)0/U <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 rest 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 Nam 13.Thins l� rte( �flgms were tested on the date(s)shown.Those indicated as"Tight"meet the criteria establls by the <br /> CERTIFICATION Ull SO JIICIP^al Association Pamphlet 329. <br /> J 4 PsTjlattr r Com any. By Sgnature <br /> Sepal No.of Thermal Certification* LC w���NyV+ <br /> SlimSensor <br /> 2 <br /> Cenihcation• PN6827 <br />