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71-Z/(-23 <br />Data Chart for Tank Systemi est <br />PLEASE PRINT <br />1. OWNER Property ❑ /L" �� <br />Address <br />Tank(s)Representative Telephone <br />❑ <br />me Address Representative Telephone <br />2. OPERATOR Name Address Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN Name This Company or Affiliation Date <br />ntity by D'rection Capacity Brand/S <br />5. TANK INVOLVED 7 t�d 0 a/7 <br />Ude additional lines <br />for manifolded tanks <br />vents <br />ie - <br />Approx. Age <br />Siphons$ <br />IC. 1 <br />4149 <br />Size, Manifolded ' Which tanks? <br />1s the water over the tank? <br />❑ vas XNo <br />8. FILL -UP Tanks to be filled hr. Date Arranged by <br />ARRANGEMENTS Extra product to "top off" and run tank tester. How and who to provide? Consider NO Lead. <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />Involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />11. TEST RESULTS <br />12. SENSOR <br />CERTIFICATION <br />.. Serial No. of Thermal <br />Sensor <br />- <br />Terminal or other contact <br />for notice or inquiry <br />Company <br />Additional information on any item above. Officials or others to I <br />Name <br />Telephone <br />Steel/Fiberglass <br />Pumps <br />"Li, -G! <br />Suction. Remote, <br />Blake If known <br />Telephone <br />Telephone <br />when testing is in progress or completed. Visitors or observers present during test, etc. <br />Tomb were made on the abov tank systente In iscoorderwe with tog procedures prescribed <br />jpnk Identiff ion Tight Leakage Indicated — Date Tested <br />wpm ra nrww. W ,o. War".0 <br />a. <br />ter' <br />or Comparry. By: signature <br />1 <br />INC! #; <br />@QX 9795 <br />Certification # MMWERTO, CAUFORNIA 9582J PN6827 <br />Cover Fills <br />6. INSTALLATION <br />a;�knl��I �f <br />Gro <br />DATA <br />North inside driveway, Concrete, Black Top, Size, Td ' <br />Rear of station, etc. Earth, etc. to Remote Fllls <br />7. UNDERGROUND <br />WATER <br />Depth to the Water table <br />vents <br />ie - <br />Approx. Age <br />Siphons$ <br />IC. 1 <br />4149 <br />Size, Manifolded ' Which tanks? <br />1s the water over the tank? <br />❑ vas XNo <br />8. FILL -UP Tanks to be filled hr. Date Arranged by <br />ARRANGEMENTS Extra product to "top off" and run tank tester. How and who to provide? Consider NO Lead. <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />Involved <br />10. OTHER <br />INFORMATION <br />OR REMARKS <br />11. TEST RESULTS <br />12. SENSOR <br />CERTIFICATION <br />.. Serial No. of Thermal <br />Sensor <br />- <br />Terminal or other contact <br />for notice or inquiry <br />Company <br />Additional information on any item above. Officials or others to I <br />Name <br />Telephone <br />Steel/Fiberglass <br />Pumps <br />"Li, -G! <br />Suction. Remote, <br />Blake If known <br />Telephone <br />Telephone <br />when testing is in progress or completed. Visitors or observers present during test, etc. <br />Tomb were made on the abov tank systente In iscoorderwe with tog procedures prescribed <br />jpnk Identiff ion Tight Leakage Indicated — Date Tested <br />wpm ra nrww. W ,o. War".0 <br />a. <br />ter' <br />or Comparry. By: signature <br />1 <br />INC! #; <br />@QX 9795 <br />Certification # MMWERTO, CAUFORNIA 9582J PN6827 <br />