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,f <br /> Data Chart for Tahk System Tightness Test <br /> �* <br /> PLEASE PRINTSTATI ON DATE <br /> 1. OWNER Property❑ <br /> Tank(s)EI Name �� Address Repn»erttatitle ebptoM <br /> ccs <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name _ Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fulty) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name iZGv rue Company or Affiliation Date <br /> Address Telephone <br /> Identity by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 5. TANK INVOLVED <br /> 'e < <br /> Use additlonal lines <br /> tot manifolded tanks <br /> Location Cover Fills Vents Siphones Pumps <br /> 6. DATA INSTAELATION �� If <br /> Vic( <br /> North inside driveway, Concrete.Black Top, Size.Titefill make,Drop Suction,Remote, <br /> Rear of station,eta Earth,etc. tubes.Remote Fills Sze,Menifolded Which tanks? Make d known <br /> 7. UNDERGROUND ll tt Is the water over the tank? <br /> WATER Depth to the Water table rl �E�p —\ fl'�Yrs' ❑yea <br /> 8. FILL-UP Tanks to be filled 'i"�"hr —Z� `�Date Arranged byName Telephone <br /> ARRANGEMENTS Extra product to'Top otr and run tank tester. How and who to provide? Consider NO Lead. <br /> I Terminal or other Contact <br /> for notice or inquiry /y/' <br /> 4�_—a= �4 <br /> Company Name Telephone <br /> 9. CONTRACTOR. <br /> MECHANICS, <br /> any other contractor — <br /> involved <br /> 10. OTHER `�` �S°+2r w — <br /> INFORMATION � ` <br /> OR REMARKS l nyL_ Izc ` ,� ra.U�K# <br /> Ad:_I on f information on any items above.Officials or others to be advised when testing is in progress or complM .Visitors or observers present during test,etc. <br /> I <br /> Tests were made on the above tank systems In accordance wish test procedures prescribed for <br /> 11. TEST RESULTS as detalled on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> II <br /> i <br /> I <br /> 12. SENSOR 13.This Is to tarttty that theals tank sylsteme were bated on the date(s)shovrrt.Thome WdIcalted as 1"9W ffleel thaf of arta established by the <br /> CERTIFICATION fiauond tare Prowcoon Association Pamphlet 329 <br /> Technicians <br /> Date <br /> 1. <br /> ,�(1 ��TT'eating Crontreetor or Com 1 rNtun <br /> t Senal No.of Thermal Certification a ~?—I t 1919 MF'dCKGI DA-►�LkND f C.A `���� <br /> Sensor <br /> Address <br /> 2 <br /> �� Certification 0 PN68Z7 <br />