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Data Chart for Tank System Tightness Test <br />PLEASE PRINT <br />1. OWNER pgpwY❑ <br />Ta1Mls) ❑ <br />AOouanzip <br />b vx <br />iw <br />Telephone <br />Name Amren. <br />ZiD <br />Repreaenmtwe <br />Temphow <br />2. OPERATOR <br />Nam® Addmae ZtD <br />Twepnone <br />3. REASON FOR <br />R is <br />c <br />TEST <br />(E.Wn Fully) <br />4. WHO REQUESTED <br />d Ps^ a <br />f N <br />- <br />i"; <br />sle Domwnv " ninauo <br />Deta <br />TEST AND WHEN <br />Amresa z,p <br />uomiy DY Direnion Cvb—Y Bunds ..' Grebe <br />Abb..., <br />Tetepn <br />SteN/Floergl <br />5. TANK INVOLVED <br />ovy OEG <br />tPU L_ <br />--- <br />U. mdnbnal bms <br />mr matlaadvd larks <br />- <br />------. <br />6. INSTALLATION <br />LOWan DOwr <br />/1%D 1'�� ®� �st06 Efe <br />Fns sora <br />�j%yr D3 fy <br />aiphonas <br />Prinmps <br />O��wev_c <br />DATA <br />7:61a n <br />Nonh -or drivew.Y DorlClete. B4 Tbr <br />Raer DI aretlon. elc Eenh. etc <br />I six,. Tirefiq make. Drop <br />loose. RamlHe qua Sixe, amnitoldm <br />—h tank, -I <br />eutlp>n. Remote. <br />MMa n known <br />7. UNDERGROUND <br />3 H <br />`i <br />remewmwwertremn"' <br />❑Y«� <br />WATER <br />Dorm latm.mbrtmN hOro Erma <br />gN EmS <br />8. FILL -UP <br />Tana. m mhllea�� r. <br />..l. Anmged by <br />Name <br />al spoons <br />ARRANGEMENTS <br />c <br />S o R i o <br />e <br />s t: -e <br />E j <br />_ Sgn <br />comwny Neme <br />T.Neorane <br />9. CONTRACTOR, <br />r <br />MECHANICS, <br />.-olved conlrador <br />In yes <br />— <br />5 <br />P y' <br />10. OTHER <br />INFORMATION <br />Data Chart for Tank System Tightness Test <br />PLEASE PRINT <br />1. OWNER pgpwY❑ <br />Ta1Mls) ❑ <br />AOouanzip <br />b vx <br />iw <br />Telephone <br />Name Amren. <br />ZiD <br />Repreaenmtwe <br />Temphow <br />2. OPERATOR <br />Nam® Addmae ZtD <br />Twepnone <br />3. REASON FOR <br />TEST <br />(E.Wn Fully) <br />4. WHO REQUESTED <br />d Ps^ a <br />f N <br />- <br />i"; <br />sle Domwnv " ninauo <br />Deta <br />TEST AND WHEN <br />Amresa z,p <br />uomiy DY Direnion Cvb—Y Bunds ..' Grebe <br />Abb..., <br />Tetepn <br />SteN/Floergl <br />5. TANK INVOLVED <br />ovy OEG <br />tPU L_ <br />--- <br />U. mdnbnal bms <br />mr matlaadvd larks <br />- <br />------. <br />6. INSTALLATION <br />LOWan DOwr <br />/1%D 1'�� ®� �st06 Efe <br />Fns sora <br />�j%yr D3 fy <br />aiphonas <br />Prinmps <br />O��wev_c <br />DATA <br />7:61a n <br />Nonh -or drivew.Y DorlClete. B4 Tbr <br />Raer DI aretlon. elc Eenh. etc <br />I six,. Tirefiq make. Drop <br />loose. RamlHe qua Sixe, amnitoldm <br />—h tank, -I <br />eutlp>n. Remote. <br />MMa n known <br />7. UNDERGROUND <br />�� <br />�lo�/� /(Je� <br />remewmwwertremn"' <br />❑Y«� <br />WATER <br />Dorm latm.mbrtmN hOro Erma <br />8. FILL -UP <br />Tana. m mhllea�� r. <br />..l. Anmged by <br />Name <br />al spoons <br />ARRANGEMENTS <br />E.- -d0 t 1010P.11 tank tmte1. raw« am ..no 1. prom«v c0n.iee, NO 19m. <br />e <br />s t: -e <br />Tmrnal Or Ore. cooled. <br />for mow Or inquiry <br />comwny Neme <br />T.Neorane <br />9. CONTRACTOR, <br />MECHANICS, <br />.-olved conlrador <br />In yes <br />— <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />rmnanai mbrnmrwrl a. -b- aco+e. Gebiela o, <br />inners t0 a seised wnm, tmhng ism w0 Nr <br />or IMPpW . vi- 0r Ohs 1 wesent <br />during mal. n <br />11. TEST METHOD <br />[K PETRO TITEM <br />❑ PETRO COMP <br />❑ QUICK CHECK 2000 <br />Tab arae made at the above tw* systWft M accordance with rep prescribed for <br />11 a. TEST RESULTS <br />a daalled at attached <br />tar minis won raulb se follows: <br />TW IdenNliWW Tight <br />NNYqumechwla Pa Nine <br />DateT.- <br />rx O/ <br />12. SENSOR <br />13. CONTRACTOR.CER IF <br />AFFORDA TEST <br />CERTIFICATION <br />POB 436 <br />b' - nt-moi j <br />Taamkana <br />THORNTON,CA.95686 <br />�e <br />or! TM ' <br />ww - <br />Cwtp � O <br />. Taatilu ContmO w ca ,. ev_- Bgnature <br />OM,Nd <br />