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I*Data Chart for Tank Sy .em Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER Proper,❑ yr., � <br /> Tank(s)❑ Na C O / rasa - �•' <br /> �j (� Repr6sentetive Telephone <br /> Name Address <br /> 2. OPERATOR Re0`ea Telephone <br /> Name Address <br /> 3. REASON FOR elephone <br /> / '','�f:U,�'VI. - � �,� <br /> TEST J <br /> (Explain Fully) i <br /> 4. WHO REOUESTED <br /> TEST AND WHEN Name Titb <br /> Company or Affiliation Oeta <br /> Address <br /> Telephone <br /> Identify by Direction Capacit Brmnd/S Iter Gre� <br /> 5. TANK INVOLVED Aw°x ewe st /FlMrglau <br /> l/se additional lines <br /> for menlfolded tanks <br /> Location Cover Fills Veno <br /> 6. INSTALLATION ye,�Q�-j�p G / S'ph°^« Pump$ <br /> DATA �p�t��L?�'�—� �} �� ) 7Z; <br /> w C vl/ � <br /> L��b <br /> North Inel driveway, Concrete,Black Top, Size,Thefill makeDrop <br /> p <br /> Rear of station,etc. Earth,etc. tubes,Remote Fills Size.Ahan <br /> nllolded Which tanks? Suct1on,Re, <br /> 7. UNDERGROUND Make If kenownmot <br /> WATER Is the water over tM hnk? <br /> Depth to the Water table <br /> ❑yes <br /> 1. FILL-UP Tanks to be filled hr. Date Arranged by <br /> ARRANGEMENTS Extra product to"top off and run tank tester. How and who to provide? Consider NO Lead. Name Telephone <br /> Terminal or other contact <br /> for notice or Inquiry <br /> Company Name <br /> Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> Invol <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any Items above.Officials of other to be advised when testing is In progress or <br /> congleted.Walton or observer present during test,etc. <br /> 11. TEST RESULTS Tests were made on the above tank systema In accordance with test Procedures prescribed for <br /> as detailed on attached test charts with reattiis as foNows• <br /> Tank Identification Tight Leakage In called. LJ� <br /> Date Tested <br /> Gr <br /> 12. SENSOR 13.This Is to certtfy that two tertk"ams war.%Mod on the Wxmm Those kfdicated a <br /> ai Fire P'°t.ction P�atttphfst 32a 'Pont rnsel the C!'"01111111C!'"01111111 estabNshed by the <br /> CERTIFICATION Nation <br /> rel &q, <br /> Tearing Contractor or Company. By: Signature <br /> Phi No.of Thermal Certlfleatlon e <br /> Sensor <br /> 2 , <br /> P. O. BOX 9795 <br /> Oirt1fleM1or$ SACRAMENTO,CALJFORNIA 96823 <br /> PN6B27 <br />