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Oata chart for Tanit Syson Tightness <br />u: <br />i <br />PLEASE PRINT <br />r <br />1. OWNER Property ❑ <br />j" Tanks) ❑ "/J Address <br />i Name Address <br />Zip Representative <br />Zip Representative <br />2. OPERATOR _ <br />Name Address Zip Tefep no <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN Name <br />Adeft.— <br />or Affiliation Date <br />Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identil by Direction <br />- _� <br />Capacity <br />Brand/ upplier <br />Grade <br />Ca <br />Approx. Age <br />Steel/ F r ass <br />-- <br />--- - <br />6. INSTALLATION' <br />DATA <br />L r <br />/�1r <br />Northinside driveway, <br />near of station, etc. <br />Cover <br />Otlae� <br />Concrete, Black Top. <br />Earth, etc. <br />Fills <br />Size, Titefill make, Drop <br />lubes, Remote Fills <br />Vents <br />A. <br />Size, Manifolded <br />Siphones <br />Which tanks? <br />Pu <br />Suction, Remote, <br />Make if known <br />7. UNDERGROUND Is the water over me rano-r <br />WATER Depth to the water table from Ll Yes ONO <br />6. FILL UP Tanks to be filled hr.�Dbte Arranged by <br />Name Telephone <br />a:. <br />'ARRANGEMENTS Extra product to 'lop oft" and run tank tester. How 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 / 1 <br />Involved <br />10. OTHER �;Z'x-- <br />INFORMATION --- OR REMARKS / <br />Additional Information on any Items above. Officials or olhers to be advised when testing is in progress or completed. Visitors or observers present during lest, etc. <br />11. TEST METHOD ® PETRO TIT ❑ PETRO COMP ❑ QUICK CHECK 2000 <br />Tests were made on the above tank systems In accordance with test procedures prescribed for <br />11a. TEST RESULTS as detailed on attached test charts with results as follows: <br />Tank Identift ation Tight Net Volume Change Per Hour Date Tested <br />12. SENSOR 13. CONTRACTOR CERTIFICATION (ANGLE INC. OF SACRAMENTO <br />CERTIFICA ION P.O. BOX 231067 <br />-//- _ h" SACRAMENTO, 95823.1067 <br />/9 Testing Contractor or Company. By: Signature ' <br />Ser al, No. of Thermal <br />al Certification e /�q� j�C Y <br />Sensor Address <br />2 <br />/� <br />Certifications PNO827 <br />