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LEASE PRINT <br />Data Chart for Tank System TightnesseT st <br />1. OWNER Property ❑ <br />Tank(e) ❑ <br />L- 4(X <br />hers" Address Fapreesnitalve Telptwne <br />f Mthe Address <br />tatM Telpfaone <br />2 OPERATOR <br />Name <br />Telephone . <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />- <br />4. WHO REQUESTED <br />TEST AND WHEN <br />",k\ Q <br />No" TNte Company or Affiliation Date <br />Address <br />Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manlfofded tanks <br />identify by D"dionMbergless <br />!-`j�:' 4-)t Cj - <br />GPacttY <br />ltrsnd/SuppGer <br />� <br />Lit <br />do <br />Ap°r°'lKrxu <br />S. INSTALLATION <br />DATA <br />locationelle <br />North inside drivtway. <br />Row of Nation, etc. <br />Concrete. black Top. <br />Earth. etc. <br />Site. TReHN make. Drop <br />• tubes. Remote Fills <br />ventsnones <br />- <br />Site. Msnifolded <br />Sip <br />Which tants? <br />Pun" <br />suction. Remote. <br />Make N known <br />'. UNDERGROUND <br />WATER <br />, <br />• Depth to the water is alt 3`� I l <br />a the water ow the tank? <br />❑ yes ❑ t+o <br />I. FILL -UP <br />ARRANGEMENTS . <br />Tanks to be litled hr. Data Arranged by <br />Extra NYAe <br />product to -top otr and run tank tester. How and who to provide? Consider No Load. <br />T*'°hove <br />Terminal or cMer contact <br />.for notice orJraquiry <br />Company Norse <br />- <br />TNephone <br />CONTRACTOR, <br />MECHANICS, <br />any Other Contractor <br />nvolvsd . <br />). OTHER <br />INFORMATION <br />OR REMARKS <br />Addhionat information on any items above. oniciols or others to be advised when testing is M progress or completed. Visitors or obesrwrs present during test. etc. <br />I. TEST RESULTS <br />Teets were made on rtes above tank system In socordeft°' with lest procedures prasscrlbsd for <br />as detaW on attached fast charts with r*Kft as follows: <br />Tank tdentiheation Tight Leakage tndieeed Date Tested <br />SENSOR <br />CERTIIFFiICATI�OyN+� <br />) - •,.. <br />13.THe M b oMMy tltat 11+aee tank aystartts were Meted any. .t,gy,n ntga. kk$CaW vw asby 9W <br />Techniciansi <br />Neftniii Fire ProbefM A690gadon pamphlet JIM 7�f <br />t77;)y —C�t1 am t�zr>>_.,. int <br />Testing 1'Y. <br />setterSensor t GrtN len.Ca rdl <br />Address <br />