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i;:i <br />N 0 V 1(! 1988. <br />QUIK STOP. MARKEIS <br />EASE PRINT <br />1. OWNER Property iLJ <br />Tank (a) Name� <br />Name <br />2 OPERATOR <br />Nem" <br />3. REASON FOR <br />TEST <br />fExplaln Fully) . <br />4. WHO REQUESTED <br />TEST AND WHEN <br />s <br />Data Chart for Tank SystemTightness Test <br />�YDA &A -hr '* Nom_ P_ D. BOY S?�/s' ►=Q'E11tn�)4"' i��_ <br />' Address Representative ✓✓ ' Telephone <br />Address Representative Telephone <br />aA..R.t'r' 132 <br />Mrs's- <br />Address <br />SSSAddress Telephone <br />BASS MLR Qul Amo /k►il:rE'6t'�7"S /N L.. <br />TitlCompany or Affiliation * - Date <br />e <br />Address Telephone <br />Identify by Direction capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steef/Fiberglass <br />5. TANK INVOLVED : <br />ARRANGEMENTS <br />Psora product to "top off' and run tank taster. flow and who to provide? Consider No Lead. <br />Terminal or other contact <br />4400 Aeg— <br />for notice or Inquiry <br />Company Name Telephone <br />9. CONTRACTOR, <br />Use additional lines <br />for manifolded tanks <br />MECHANICS, <br />- <br />- -` <br />Involved <br />10. OTHER <br />---- <br />INFORMATION <br />OR REMARKS <br />_. <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 />Location Cover <br />Fids <br />Vents <br />Sfphones <br />Pumps <br />6. INSTALLATION 005r' so' <br />�v <br />.. <br />,� <br />DATA <br />003 Z. DA, <br />S <br />12. SENSOR <br />JSG1llt/�S <br />CERTIFICATION <br />mationd Af" 329` <br />Datet. <br />Technicians <br />�il:� ✓D TIG".� /� <br />North Inside driveway, Concrete, Bieck Top, <br />She, Tltegll make, Drop <br />Sensor <br />,t\^� <br />Ce'tiffcatlott a _I/ n ' /////} �. / <br />Ly6J &Ey / �F71C �i !J 1 ! -A -9 7 117— _ <br />Suction, Remote, <br />Rear of station, etc. Earth, etc. <br />tubes, Remote Fills <br />I <br />Size, Manifolded <br />Which tanks? <br />Make If known <br />7. UNDERGROUND <br />WATER <br />la the water oder tNo k? <br />GB�Ti�f�if//:?E ❑ <br />Depth to the Water table /4 raa f o <br />8. PILE-UP <br />Tanks to be filled hr. Date Arranged by _ <br />Name Telephone <br />ARRANGEMENTS <br />Psora product to "top off' and run tank taster. flow and who to provide? Consider No Lead. <br />Terminal or other contact <br />for notice or Inquiry <br />Company Name Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />Involved <br />10. OTHER <br />---- <br />INFORMATION <br />OR REMARKS <br />_. <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 />11.. TEST RESULTS <br />Tests were made on the above t In accordance with test procedures prescribed for <br />as retailed on attached tact cheats with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />003 Z. DA, <br />S <br />12. SENSOR <br />13. Tw Is to car" that these tank systim ware on the date(e) ahown. Those Indicated as "TW maaRtha offleft established by the <br />CERTIFICATION <br />mationd Af" 329` <br />Datet. <br />Technicians <br />�il:� ✓D TIG".� /� <br />Serial No. of Thermal <br />.t(��' <br />Testing Contract r or Company. rSignature <br />Plc_ /O Jo ` L <br />Sensor <br />,t\^� <br />Ce'tiffcatlott a _I/ n ' /////} �. / <br />Ly6J &Ey / �F71C �i !J 1 ! -A -9 7 117— _ <br />Address <br />2 <br />Cer"fi 0 <br />