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,4 <br />lata Chart for Tank a s m Tightness Test <br />PLEASE PRINT <br />1. OWNER Property ❑ <br />N <br />Tank(s) Address Zip Representative Telephone <br />❑ <br />Name Address Zip Representative Telephon <br />47 <br />2. OPERATOR 7 <br />Name Ad ss Zip Telephone <br />3. REASON FOR – % <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED — 6' -- 2/ <br />TEST AND WHEN Name Title Company or Affiliation Date <br />Address Zip Telephone <br />Ider^ by Direction C. <br />5. TANK INVOLVED Gt �'/�G� <br />Use additional lines <br />for manifolded tanks <br />Capadt <br />Brand/Supplier <br />Grad Approx. Age Steel/Fiberglass <br />z <br />--- <br />--- <br />Lop"550 <br />6. INSTALLATION <br />DATA <br />p9DdCJ <br />North inside driveway. <br />Rear of station. etc. <br />Cover <br />&9 <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />Size. Titefill make. Drop <br />tubes, Remote Fills <br />Vents Siphones Pu <br />Suction. Remote. <br />Size, Manifolded Which tanks? Make it known <br />7. UNDERGROUND <br />WATER <br />8. FILL -UP <br />ARRANGEMENTS <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />Involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />11. TEST METHOD <br />11a. TEST RESULTS <br />12. SENSOR <br />–CER JIFI TION <br />IN No. of Thermal <br />Sensor <br />r <br />y I - <br />Depth to the water table <br />Tanks to be filled�fic 72 -1,A to Arranged by _ <br />Extra product to 'top off' and run tank tester. How and who to provide? Consider NO lead. <br />Terminal or other contact�> <br />for notice or Inquiry <br />Company <br />Is the water over the tank? <br />L1 Yes kNo <br />Name Telephone <br />Name / �' J Telephone <br />/0,A �f'v <br />es� <br />Additions information on any Items above. Officials or othe,s to be advised when testing is in progress or completed Visitors or observers present during test, etc. <br />PETRO TIT ❑ PETRO COMP ❑ QUICK CHECK 2000 <br />Tests were made on the above lank systems in accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Tan Identification / Tight Net Volume Change Per Hour / Date TTeskd <br />_ r Gm / __ L•- - / <br />13. CONTRACTOR CERTIFICATION <br />:! — Z Z <br />Certification s <br />TRIANGLE INC. OF SACRAMENTO <br />P.O. BOX 231067 <br />SACRAMENTO, CA 95823-106 <br />Testing Contractor or Company <br />By: Signature <br />PN6827 <br />