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Data-.Chart -for Tank System Tightness Test <br /> PLEASE PRINT 't <br /> 1. OWNER Properly❑ 15� �n��'d/� 1� � �� 0 IT... n� i h e t <br /> Na n�,,,�,// —f Re re nta5 Telephone <br /> Tank(3)❑ Ana, 7�� <br /> Name—� Address ip Reoresentative Telephone <br /> 2. OPERATOR NamaTelaonone <br /> Address Zip <br /> 3. REASON FOR w=l j-71 r0ce- s /91rL��Ad'S <br /> TEST <br /> fExolain Fully) <br /> 4. WHO REQUESTED Lze 5;�rV le z c fD_/x4-3 <br /> TEST AND WHEN '"1e rue COmoarry�Afftlial 0ale <br /> / fl/ r o ev� 1.n ,-� ac �c . <br /> Address Zip Telephone <br /> Identify by Oirection Capacity �/ Brand,supplier Grade Approx.Age SleeUFberglass <br /> 5. TANK INVOLVED "Sr, czar 1-'� c,51 Lf_ri if <br /> v <br /> Use additional lines <br /> for manifolded tanks <br /> location _1� Cover Rus /r Vents Sipno� Pumps <br /> - <br /> 6. INSTALLATION /00)-- )1 O-J: /��'. 1� a <br /> DATA ,g UAb 707 , <br /> North inside drtveway, Concrete.Black Top. Site.Titefill make.Drop Suction.Remote. <br /> Rear Of station,M. Earth,etc tube.Remote Fills Sze.Mandolded Which tanks? Make it known <br /> 7. UNDERGROUND �G . Is the(watef over <br /> rttthhe tank? <br /> WATER Oeath to the water table from grade ,�� /7 C /�� /f/— «� '—yes ANA <br /> 8. FILL-UP Tanks to be fined L'1:20 hr./C 63 Oate Arranged by r( ' <br /> Name Telephone <br /> ARRANGEMENTS Extra product to'lop oif and run tank tester. How and who to prdatnde? Consider NO lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 9. CONTRACTOR. �l ~ <br /> MECHANICS, <br /> any other contractor <br /> Involved <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS ___ <br /> Additional informaab <br /> lton on any items ove.Dflicials at Others to be advised when testing is in progress or completed.Nsitors of observers present during test.etc. <br /> 11. TEST METHOD ® PETRO TITE:�E ❑ PETRO COMP ❑ QUICK CHECK 2000 <br /> Tests were made on the above tank systems in accordance with test procedures prescribed nor <br /> Ila. TEST RESULTS as detaAed on attached test charts wltt+twists as 10flows' <br /> Tank identification Tight Net Volume Change Per Hour Cate Tested <br /> �P a Z /O /—cT� <br /> Th Za <br /> ET- i- - <br /> 12. SENSOR <br /> 13. CONTRACTO.B WTIFICATION AF FOROA TEST <br /> CERTIFICATION POB 436 <br /> --� Technicians 7.1 RNTONXA. 95188 <br /> W4 01MM Daa <br /> Testlnq Contractor or Company. By: Signature <br /> Senal No.of Thermal FCaation s c - <br /> Sensor <br /> Address <br /> 71Y <br />