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i <br />PLEASE PRINT <br />1. OWNER Property ❑ <br />Tank(s) ❑ <br />Ota oTank Tightness <br />Address Zip Representative Telephone <br />Address Zip Representative _/Telephone <br />2. OPERATOR — ri_�:vrr�i �i vim, r,�✓� /r r�� I`.�� �_- — <br />N e Address Zip Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN Name Title Company or Affiliation Date <br />Address Zie Telephone <br />identify by Direction <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Capacity_ <br />Brand/ pplier Grade <br />Approx. Age Steel/Fiberglass <br />— <br />— --- - <br />Pon <br />6. INSTALLATION <br />I DATA <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />Concrele, Black Top, <br />Earth, etc. <br />fills vents <br />Size, Titefill make, Drop <br />lubes, Remote Fills Size, Manifolded <br />Sfphones Pum <br />s <br />Suction. Remote, <br />which tanks? 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 />11a. TEST RESULTS <br />12. SENSOR <br />CERTIFICATION <br />_� <br />rial No. of Thermal <br />Sensor <br />i <br />i <br />-1 <br />i, <br />is the water over the lank <br />Depth to the water table from gra—_�__G�- LJ Yes 0 No <br />Tanks to be filled ' ` hr. / / Date Arranged by <br />Name Telephone <br />Extra product to 'top off' and run lank tester. How and who to provide? Consider NO Lead. <br />Terminal or other contact f'� /A ri <br />for notice or Inquiry _.—_�(./ Yom/ — <br />Company Name Telephone <br />Additional infer anon 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 />jZ PETRO TITt�� ❑ 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 />Tank Identification Tight Net Volume Change Per HourDate tested <br />' I— ..,. -.--—T—i-r^ — w-. B%1 / a -- <br />13. CONTRACTOR <br />2 ' ` / <br />Certification M <br />TION TRMGLE INC. OF SACRAMENM <br />P.O. BOX 231 7 <br />T0. 95823.10 <br />,s.e / j Testing Contractor or Company. By: Signature <br />Address <br />A <br />J <br />PNS827 <br />