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s <br />PLEASE PRINT <br />r <br />1. OWNER Property ❑ <br />Tank(s) ❑ <br />I <br />' 2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />data Chart for Tank Syom Tightness Test <br />Address <br />Address <br />Name <br />Name Title <br />Address <br />Zip Representative Telephone <br />Zip Representative Telephon <br />Zip Telephone <br />Company or Affiliation Date <br />Zip Telephone <br />Ida by Direction, <br />5. TANK INVOLVED `'r// <br />Use additional lines <br />for manifolded tanks <br />Capacity <br />f(/l <br />Brand/SuppNer <br />�(!/%j <br />Gred Approx. Age <br />Steel/Fiberglass <br />r <br />—" <br />--- <br />— <br />Lo p�G" <br />6. INSTALLATION <br />DATA <br />North inside driveway, <br />Rear of station, etc. <br />cover <br />Concrete. Black Top, <br />Earth, etc. <br />Fills <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Vents Siphones <br />Size, Manifolded Which tanks? <br />Pu / <br />Suction, Remote. <br />Make if 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 />Ila. TEST RESULTS <br />Depth to the water table from grads-✓ /" 4� <br />Tanks to be filled_ems' te Arranged by <br />Da <br />Extra product to 'top off' and run tank tester. How and who to provide? Consider NO Lead. <br />Terminal or other contactjet <br />for notice or Inquiry <br />Company <br />Is the water over the lank7 <br />F-1 Yes j?No <br />Name Telephone <br />Name Telephone <br />Addtliona information on any Items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present during lest, etc. <br />aPETRO TITW ❑ PETRO COMP ❑QUICK CHECK 2000 <br />Tests were made on the above tank systems In accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Ten Identification Tight Net Volume Change Per Hour Date Tested <br />12. SENSOR I 13. CONTRACTOR CERTIFICATION <br />Certification ev <br />2 <br />Certification 8 _ <br />TRIANGLE INC. OF SACRAMENTO <br />P.O. BOX 231067 <br />SACRAMENTO,Ch 95823.10 C1441F� <br />Testing Contractor or Company. BY: Sipnatwe <br />Address <br />. i. <br />PN602T <br />