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HomeMy WebLinkAboutApplication for Permit to Maintain and Existing/New Underground Storage Facilit - Permits - 3 MASSACHUSETTS AVENUE 10/20/1994 The Commonwealth of Massachusetts Department of Public Safety Division of Fire Prevention and Regulation APPLICATION FOR PERMIT TO MAINTAIN AN EXISTINGMEW UNDERGROUND STORAGE FACILITY '10: Bead of Fire Department North Andover October 20 1994 City, `Fown or District Date Application is hereby made for a permit to maintain an existing/new underground storage facility as required by 527 CvIR 9.00: Perinits. location of` property: 3 Massachusetts Avenue Street Address Owner of property: Patob Realty Trust Full name of person, firm or corporation Si&mature of owner or authorized representative: F/i , � _ ,_}� FEE: $ 10 . 00 0I.G.L.A. Chapt. 148,Sec. 10A) r FOn?A F.P. 290 (Fire department's copy to be filed with F.P. 290 Part 2) (rev. 10/90) The Commonwealth of Massachusetts Department of Public Safety Division of Fire Prevention and Regulation PERM IT Oct. 20 19 94 Date TO MAINTAIN AN EXISTINGMEW UNDERGROUND STORAGE FACILITY In accordance with the provisions of 527 CMR 9.26 this permit to maintain an existing/new underground storage facility is granted to: Location of property: 3 Massachusetts Avenue Street address owner of property: Patob Realty Trust u Full name of person, ff- or corparatlon Restrictions: MUST MAINTAIN- OM SECTIONS 9 , 10A and 13 and 527 CMR .5, 8 , 9 and 10 WHERE APPLICABLE is s Fee Paid:$ 10 . 00 (M.G.L.A. Chapt. 148 Sec. 10A) This permit will expire/v /Nd 19 Datf IgnRtur• of 11eed of plr• Oepi, or eppelnled designer FOnM F.P. 290 (rev. to/so) e. (Owner's copy to be posted at the storage facility) 1.9 1(w1.wAiw1W119ya41 ellltV - Notification for Storage Tanks Regulated Under.527 CMR 9.00 Forward completed form, signed by local fire department, to: Mass. UST Program, T office of the State Fire Marshal, 10i0 Commonwealth Ave., Boston, MA 02215 ived:(Fire Department retains one copy of FF'-290) iDt#D A. Nevin Facility(see instructions,It1) ❑ B. Amended ❑ C. Renewal rep .Sig. No. of tanks at facility No. of continuation sheets attached _ INSTRUCTIONS: Form FP-290(Notification for Aboveground and Underground Storage Tanks)Is to be completed for each location containing underground or aboveground storage tanks regulated under 527 CMR 9.00. It more than live tanks are owned at this location,photocopy the fallowing pages and staple continuation sheets to the form. The FP-290 must be 7A. Faclilly Number completed In duplicate. Although the form may be pholocopied,the facility owner or owner's representative must sign eachcopy separately;photocopied s€gnatures are not sufficient. Both copies of the FP-290 are to be forwarded to the local Entered lire department,who will check all Information and certify the forme. The lire department will retain one copy of the FP- 290 for Its records,and the facility owner shall be responsible for forwarding the other copy to the Office of the Slate C. Clerk's Initials Firs Marshal at the address above. The local lire department will Issue the permit portion of the FP-290:however, registration Is not complete until lho FP-290 Is received and checked by the office of the State Fire Marshal. All questions on D.Comments ibis form are to be answered.Incomplete forms will be returned. ''New Faculty'means a tank or tanks located at a site where tanks have not been previously located. _"Facility street address"must include both a street number and a street name. Post office box numbers are not acceptable, and will cause a registration to be returned.If geographic location of facility Is not provided,please indicate distance and direction from closest intersection,e.g., (facility at 199 North Street Is located) (Intersection). . N otification Required FxcS9tifltl:(a)a farm or resldentlal lank of 1,100 gallons or less capacity used for storing motor evenllon Form FP 2gg 1s to ba used es Notification,Registration,and Permit for tuelfornoncommerclalpurposas,or(b)atankusedforsloringhealingo111orconsumptiveuse round and underground storage tanks and tank facilities regulated under 527 on Iha premise$where stared are not required to be registered under 627 CMR 9,00. f Massachusetts Regulations 9.00.Na rvgulaied aboveground or underground Eiwatil=Anyownerwhoknowinglyfallstonoilfyorsubmits(also Information shall be subject storage tank facility shell be Installed,maintained,replaced,substantially modified or to a civil penalty not to exceed$25,000 for each lank for which na1111cation is not given or for removed without a permit(FP-290)Issued by the head at the focal tiro department. which false Information Is submitted.(MGLChapter 148,section 381-11,527 CMR 9,00) € The owner of any storage facility shall within seven working days notify the head of the i local fire department and the State Fire Marshal of any change In the name,address, Aboveground Storage Tanks or telephone number of the owner or operator of a storage facility subject to regulation 527 CMR 9.00 requires the registration of any aboveground storage lank which meets the by Chapter 146,Mass.General Law and by 527 CMR 9.00. following definition:a horizontal or vertical tank,equal to or lass than 10.000 gallons capacity,that Is Intended for fixed Inslaltatlon without back fill above or below grade,and Is li Underground storage Tanks used Ion the storage of Hazardous Substances,hazardous Wastes,or Flammable or Each owner of an underground tank first put into operation on or alter Jan.1,1991, Combustible Liquids. '. shall,within thirty days allot the lank Is first put into operation,notifyy the Department of Public Sal; (the department)di the existence of such tank,specitying,to the extent EXceationL:Abovegroundtanksolmorethan t0,000gationscapacltyreguiatedby520CMS known,its$owner o1 tits tank,dale of Installation, capacity,type,laeai on,and uses of 12.00(Requirements far the Insiallatlon of Tanks Containing Fluids Other Than Wafer In such lank.By no later than Jan.31,1991,each owner of an underground storage tank Excess of 10.000 Gallons)are not required to be registered under$27 CMS 9.00. that was In operation at any time after Jan.1,1974, regardless of whalhor or not such ExQ0pU0a1 :(a)a farm or residential lank of 1,100 gallons or less capactly used for storing tank was removed from beneath the surface of Ilia ground at any lime,shall notify the motor fuel lot noncommercial purposes, or (b) a tank used for storing healing oil for department of the existence o[such tank,specifying,to the extent known,the owner of consumptive use on the premises where stated are not required to be registered under 527 the tank.data of Installation,copeclly,type,and location of the tank,and the typo and CMR 9.00. quantity of substances stored in suchh tank,or which were stored In such lank before ihalankoeaubstanesssed being in oedInontflholankwasremovedfrombeneatltthesurlace PAna mAnypersonwhoknowingtyvlolalesanyruleorregulationmadebytheBoardaIt=ire of the ground prior to the submittal of such nonce to the department,Such notice shall P(evontlon Regulations shall,except as otherwise provided,be punished by a fins o!not lass also spedty,to the extant known,the data tiro lank was removed from beneath the than ono hundred dollars not more than one thousand dollars. (MGL.Chapter 148,section sudaco of the ground pilot to the submittal of such notice to the department.The 10B,and 527 CMR 9.00) operator of any lank that has no owner or whose owner cannot be definitely Where to Notify?Two completed notification forms should be signed by both the tank owner ascertained,shall notify the department of the existence of such tank,spa lying,to the and the total lire department.Ono copy will be retained by tiro lire dopartment,and Iha lank extent known,any Iniormatlon totaling to ownership of the tank,and date of owner shall sand a separate copy 10 the address at the top of this page. Installation,capacity,type,and location of the lank,and the typo and quantity of substances stored In such tank,or which were stored In such lank before the ten% When to Notify?1.Owners at storage tanks In use or that have been taken out of operation ceased being in operation If the tank was removed from beneath the surface of the must notify within thirty days. ground prior to the submittal of such notice to the department.it the tank was Owners and Operators of Regulated Storage Tank Systems must msintaln roaords abandoned beneath the surface of Ilia ground pilot to the submittal of such notice to certifying that all leek datectlon,inventory control and tightness testing requiremonts the department,such nonce shall also specify,to the extent known to the owner or for the Regulated Storage Tank system are current.These records must be roedlty operator,the date the tank was abandoned In the ground and all methods used to available for Inspecilon. stabilize the tank alter the lank ceased being In operation. 1. OWNERSHIP OF TANK(S) 11. LOCATION OF TANK(S) Owner Name(Corporation,Individual,Public Agency,or Other Entity) If known,give the geographic location of tanks by degrees,minutes,and seconds.Example:Lat.42,36, 12 N long.86,24,17W Latitude Longitude J� a T Y yjT �/�e ,�,tter Pci ! �istaaea tin direct on tom asset lore Cl sea netruCt s# Street Address ! 1 C-3 M ,'� atRvlcftl yp . V r Facility Name or Company SRe Identifier,as pitcable )at Avif f Ave y lets p a Streal Address(P.O.Box na eccepiaGa•►9e InslruMlons�M211 � r✓p� f"i U���_ CRY State Zip Coda County tt� {, ^ C)i -1,SoO 3 .3 lr 3 fix SPhorna Number I nciudAr n Codai owner's Employer Federal County Page 1 FP-290(revised 6614) III. TYPE OF OWNER IV. INDIAN LANDS. v \ Federal Government E.: Commercial C Tanks are located on land within an Indian Reservation or on State Government (storage and sale) other trust lands. - Local Gov E.Private(storage(storage and use) ❑ Tanks are owned by native American nation,tribe, or individual. V. TYPE OF FACILITY Select the AppropriateFacility Description: (check all that apply) Gas Station Marina Trucking/Transport Petroteum Distributor Railroad Ulhltles Airport Federal-Military Residential 1: Aircraft Owner Industrial Farm vehlcle Dealership Contractor Other(explain) VI. CONTACT PERSON IN CHARGE OF TANKS Name: Address: Phone Number(Include area code): Job Title: Home: Business: VII. FINANCIAL RESPONSIBILITY El I have met the financial responsibility requirements In accordance with 527 CMR 9.00. .._.........,..._.................----- -------------- ——-----....—---— Check all that apply � r ( I 1] Self Insurance I ❑ Guarantee 0 State Fund Commercial Insurance I ❑ Surety Bond I ❑ Trust Fund Risk Retention Group ❑ Letter of Credit I ❑ Other Method Allowed -Specify i VIII. ENVIRONMENTAL. SITE INFORMATION This information should be available from local health agent,conservation commission,or planning department. ' 1.Tank site located In wellhead protection area ©Yee ©No ©Unknown 2.Tank site located In surface drinking water supply protection area ❑Yea ©No © Unknown 3.Tank site located within 100 feet of a wetland ❑Yes O No ❑Unknown t , 4.Tank site located within 300 feet of a stream or water body d Yes 0 No ©Unknown' f IX, DESCRIPTION OF STORAGE TANKS AND PIPING (COMPLETE FOR EACH TANK AT THIS LOCATION) B s Tank Identification Number Tank No._�,_ Tank No. Tank No. Tank No. Tank No. i 1.Tank status a.Tank rnfes serial # (if known) b. Currently in Use 0 0 c.Temporarily Qut of Use e� -�----- -�-�— d. Permanently Out of Use u e, Aboveground storage tank (AST) or p AST KUST O AST ❑ UST ©AST D UST 0 AST ❑UST C1 AST DUST Underground storage lank (UST) 2. Date of installation (moddaylyr.) 3. Estimated Total Capacity(gallons) ad Gf/o FP-290(revised 6/94) Page 2 Tank Identification Number(cant.) Tank No.._.,,. Tank No.__L�_- Tank No. Tank No.__L4_ Tank No.-,S-- 4. Substance Currently or East Stored a. Gasoline Motor vehicle or other use D MV ❑other D MV C other CO MV L other © MV ❑other C MV D other b. Diesel Motor vehicle or other use ❑ MV D other D MV G other © MV C other ©MV 0 other D MV ©other c. Kerosene � �-- d. Fuel Oil e. Waste Oil f. Other, Please specify Hazardous Substance 0 (other than Aa thru 4e above) CERCLA name and/or CAS number ---------------- ------------ ------ ----------- Mixture of Substances Please specify 5. Material of Construction -Tank (mark all that apply) Asphalt coated or bare steel f Cathodically protected steel Epoxy coated steel 0 �� Composite (steel with fiberglass) 0 --��--1 Fiberglass reinforced plastic (FRP) Concrete 0 Other, Please specify i a 6.Type of Construction-Tank (mark all that apply) Lined interior 0 �� l Double walled P I Single walled f Polyethylene tank jacket 1 r Excavation liner Unknown Other, please specify -- I Has tank been repaired? C7 Yes No D Yes RNo o Yes 29 No ❑Yes OKNo CI Yes Cq No I Date FP•290(revised 8I94) Page 3 Tank Identification Number(cont.) Tank No. b Tank No, Tank No. Tank No. Tank No. 4. Substance Currently or Last Stored a. Gasoline Motor vehicle or other use o MV ❑other 0 MV O other ❑ MV L other ❑MV 0 other D MV O other b. Diesel Motor vehicle or other use ❑MV O other G MV G other 0 MV C other ❑MV ©other 0 MV 0 other c. Kerosene 0 d. Fuel Oil e.Waste Oil f. Other, Please specify -------------- ---- ----- ------ ----------- Hazardous Substance . (other than 4a thru 4e above) CERCLA name and/or CAS number ------ -- Mixture of Substances Please specify 5. Matedal of Construction -Tank (mark all that apply) Asphalt coated or bare steel Cathodlcaily protected steel t__.—: 71 Epoxy coated steel k Composite(steel with fiberglass) Fiberglass reinforced plastic (FRP) Q Concrete ff Other, Please specify -- a 6.Type of Construction-Tank (mark all that apply) r- � r---- Lined interior Double walled E= Single walled C� Polyethylene tank jacket Excavation liner Unknown Other, please specify Has tank been repaired? 0 Yes 18(No ©Yee 0 No O Yes O No O Yee ©No U Yes ❑No Date -- FP-290(revised W4) Page Tank Identification(dumber(cont.) Tank NO. Tank No.,_,�_- Tank No. Tank No. Tank No.,__ 2,Tank closed In accordance with 527 CMR 9.00 p Yes ONO ©Yes ❑Na ©Yes ONO G Yes ❑No Yes D No A. Evidence of leak detected ©Yes 0 No ©Yes ❑No 0 Yes C No L Yes C No D Yes EC No B. Mass. DEP notified ©Yes 0 No C Yes ONO ❑Yes ONO ©Yes E3 No E-Yes D No 1.Mass. DEP tracking number 2.Agency or company performing assessment X1. CERTIFICATION OF COMPLIANCE 1. Installation A. Installer certified by tank and piping manufacturers B. Installer certified or licensed by the ❑� ��❑ Implementing agency C.Installation inspected by a registered L� �❑ engineer D.Installation inspected and approved by the Implementing agency I E.Manufacturers'installation checklists have been completed B P. Another method allowed by 527 CMR 9.00. Please specify -- 1 2.Tank Leak Detection Tank Piping Tank Piping TanlSl Piping Tank Piping Tank Piping (mark all that apply) A. Double-wall tank- Interstitial monitoring ❑ ❑ ❑ ❑ B.Approved In-tank monitor ❑ ❑ ❑ ❑ C.Continuous vapor monitoring In soil ❑ ❑ El El D.Monthly vapor monitoring In soil ❑ ❑ ❑ ❑ ' E.Inventory record-keeping and tank testing X �( © 0 ❑ ❑ .....�......—._..._........------- F. Other method allowed by 527 CMR 9.00. Please specify 3. Piping Leak Detection (mark all that apply) A.Pressurized ❑ ❑ El El 1-1 Interstitial space monitor ❑ ❑ ❑ ❑ ❑ Automatic flow restrictor' ❑ ❑ ❑ ❑ ❑ Automatic shut-off device' ❑ ❑ ❑ ❑ ❑ Continuous alarm* ❑ ❑ ❑ ❑ ❑ " Also rewires annual lank tightness lest or monthly vapor monitoring of soil. Page 5 FP-290(revised 6194) tank Identification Number(font.) Tank No. ,e. Tank No. Tank No. Tank No. Tank No. 2.Tank closed In accordance with 527 CMR 9.00 ❑Yes ONO 0 Yes ❑No ❑Yes 0 No C Yea 0 No Ll Yes C1 No A.Evidence of leak detected 0 Yes 0 No ❑Yes ❑No 0 Yes 0 No ©Yes C No 0 Yes Ci No 13. Mass.DEP notified 0 Yes 0 No 0 Yes ❑No 0 Yes 0 No i ©Yes 0 No Z Yes 0 No 1. Mass. DEP tracking number 2.Agency or company performing assessment XI. CERTIFICATION OF COMPLIANCE 1. Installation A. Installer certified by tank and piping manufacturers '13. Installer certilied or licensed by the Implementing agency . I C.Installation inspected by a registered r7-1 engineer D.Installation Inspected and approved by the implementing agency E.Manufacturers' Installation checklists ❑� ❑ �� have been completed F.Another method allowed by 527 CMR 9.00. Please specify 2,Tank Leak Detection Tank PEping Tank w Piping Tank Plping Tank PipingrTankPiping (mark all that apply) A.Double-wail tank- Interstitial monitoring El El ❑ El B.Approved in-tank monitor ❑ ❑ ❑ ❑ ❑ C.Continuous vapor monitoring In soil ❑ ❑ ❑ ❑ ❑ is ❑ ❑ ❑ ❑ D.Monthly vapor monitoring In sail El , E.Inventory record-keeping and tank testing P. Other method allowed by 527 CMR 9.00. Please specify 3. Piping Leak Detection (mark all that apply) ❑ A.Pressurized ❑ ❑ ❑ ❑ Interstitial space monitor El ❑ El ❑ Automatic flow restrictor' ❑ ❑ ❑ ❑ ❑ Automatic shut-off device" El ❑ ❑ ElEl Continuous alarm' ❑ ❑ ❑ El ❑ Also requires annual tank lightness test or monthly vapor monitoring of soil. Page 5 FP•294(revised 6W) 11.1 ERV,ICES9 INC, GLOBAI, TANK S 4 T�ixpoti Lwie - P,O, Box 678 Someirss'woiq�n, Mri 03878 603-692,7'917 - 1 ,8(�0-2620106 August 18, 1994 ATTN: William Dolan North Andover Fire Department 124 Main. Street North Andover, MA 01845 Dear Sir, vices, Inc. recently performed underground Global Tank Serv ices, storage tank tests for Merrimack Valley Oil, Incwill. locatedfind at 3 Massachusetts in North Andover. Enclosed you copies of our result and data chart sheets. If I can be of any further assistance to you, do not hesitate to contact me. Sincerely, GLOBAL TANK SERVICES, INC. Diane C. LaCourse Business Manager GLOBAL TANK SERVICES9 INC. 4 Turgeon Lane • P.G. Sox 678 Somersworth, NH 03878 603-692-7917 • 1-800-262-0106 August 1.8 , 1994 ATTN: William O'Brien Merrimack valley Oil, Inc. 3 Massachusetts Avenue North Andover, MA 01845 RE: Underground Tank Testing Results Dear Mr. O'Brien Global Tank Services, Inc. recently performed Horner EZY Chek Leak Detection tank ovetests mentioned the siteaunderground Thetestsower rage tank e systems at the abian conducted by a certified techniaion1Pamphletm329e with thethe National Fire Protection Assoc med on the tank systems are as results of the tests perfor follows: NET VOLUME DATE TANK SIZE TANK PR4 T RESULT CHANGE passed -.009Gph 8/11/94 20, 000 gal #1 #2 oil assed -.005Gph oil 8111194 20, 000 gal #2 #2 # oil passed - .009Gph 811.2194 20,000 gal #3 passed -.009Gph 8112194 20,000 gal #4 diesel assed +.020Gph 8/11/94 10,Oo0 gal # - o27G h 8/11/94 20,000 gal #6 diesel L.S. passed h A copy of this letter and report has e been uestions the or need Andover Fire Department. If you hav Y g assistance please do not hesitate to call. Sincerely, GLOBAL TANK SERVICES, INC. Diane C. LaCourse Business Manager - K SERVICES, INC. DATA CHART FOR TANK SYSTEM TIGHTNESS TEST GLOBAL TAN (EZ 4 Turgeon Lane•P.O.Sox 678 Somersworth,NH 03878 603-692-7917 , 1-B00-262-0106 TEMPERATURE CLIENT DATE E /L _IIC� PATE OF TEST' NAME OF SUPPC]EI"1'. WEATHER OWNER OR DEALER ADDRESS(NO.&STREE-0 p ADD AND STATE 1N. CONTENTS(PRODUCT) CITYTANK MATERIAL f SIZE OF FILL OR TEST OPENING � � GALLONS APPROX.AGE -r,ntJ TANK INFORMATION GALS. r, PUMP SYSTEM�P`} CAPACITY(NO' GALS.GALS• TOP OFF TIME TEST CAPACITY(CHART) NUMBER Or GALLONS ADDED TO START DIMENSIONS: D1AMl;I ER TANK NO. AFTER LEN GG' INCHES OF WATER — rli BEFORE TEST Q--- TAr=)CL&YOUT 2x.3R _= (F 9 TEST CALIJURA=N o50 (a[.M) SIZE OF CAL.BAR OR ML'S ADDED 2 LINES LINE MOVEMENT — LINES 1 "to 5G —� ^LINES LINES 2 3 to LINES^3 = � lau+l 3 to TOTAL s IFA• G�DR At z ENO OF TEST CALIBRATION O50 (au) SIZE OF CAL SAR OFF ML'S ADDED X LINES LINE MOVEMENT _ LINES T � LINES LINES 2 �r — LINES 3=— (w1 ` 3 U to TOTAL MEASUSED API SPECIFIC GRAVITY (FROM TABLE A) PRODUCT TEMPERATURE (FROM TABLE 6) D EscL API SPECIFIC GRAV17 �s�°F c Uc � (FACTOR B) ptlmr' COEFFICIENT OF EXPANSION = VOL CHANGJ'F X - TANK CAPACITY(GAL) C.O.E. ADDITIONAL NOTES OR COMMENTS inNK l iuv3 J)A� DA EC IAN(5) DATA CHART FOR TANK SYSTEM TIGHTNESS TEST (EZY CHEK) TEMPErL4TUf3E coMPENSATION NET VOL CHANGE FROOUCT MOHfIOftING ON L1A Product PRODUCT MONRORING IN S.P. Product I +Expansion � S.P. Time Rea�ng +Gain Fates A +Lairs Start ain X Factor A start _.. End +Gain X Favor 8 -Contraction IMilivarrl I No- Star[ End I -Lcs I- '� 2 j03 5 k o Q I I I I 17 9 I --7 IrAQ ! a - :5 - n - -z A. Tank Sot. to Grade " send Report to: D � B- Tank Top to Grade '^" Client ?"ipcc-y ca f,0 C. Tank Diameter — �" Address.3 mR.Ss�C'4'Us'fTrS /9uC• GRADE D. Test Level above grade _�—' City, State No,0<1 PAIA VCR.1i.4. o/8ys E. Depth of water in tank 2—" Phone(=)683-:3131 B �,�' Attn: 61LG 0'3e/6A/ G F. Depth for taking sample " oso G . F H G. Temp. Probe depth (connector) � CEgTIFlGnON This a to aeniy itsas us Bank yste +rssm iv51C P N d � /,� p H. TESL level to Tank pQt. —ILL" on rare shown.Those indirated'•Tght•'meet the C=r a estaotishvd } n by the NaLana[Fun P=t ivn Asso6allon P—PhIet 329, I. Groundwater above tank bottom J. Product Pressure per I' height ' PSI Tank No.4/ c Tight Vr5 CIII16C /3- 004F Test Pressure Formula Leakage Indicated+ vrxum WATER E X _ D36)=_ •i•1�l DEPTH -�-z —( x - — Technician " ' t pa SSU E Date Tested aus ll 119y /\ �/' '�'/ •`ICI ,� �' ,� I _ n cOP, � I I Q C: f L GLOBAL TANK SERVICES, INC. DATA CHIART FOR TANK SYSTEM TIGHTNESS TEST (EZY cHEK) 4 Turgeon Lane•P.O.Box 678 Somersworth.NH 03878 603-692-7917 1-800-262-0106 CLIENT _ NAME OF SUPPLIER. _ _,,51 jai./� Y �!/� �}•-7"' DATE OF TEST _ .._.._..- - - WEATHER a _? Tc'MPEr'tATURE OWNER OR DEALER .% 5 .nncc rr,Cr_ r i C f?1i -� ADDRESS(NO.&STRE`-� CITY AND STATE y 'a -K� ai TANK INFORMATION " IN. CONTENTS(PRODUCT) CAPACITY(NOMINAL)_D0R GALS. SIZE OF r'ELL OR TEST OPENING GALLONS TANK MATERIAL GALS. TOP OFF TIME APPROX-AGE (- CAPACITY(CHART) NUMBER OF GALLONS ADi7-0 r START TEST DIMENSIONS: DIAMFIER PUMP SYSicM(TYPE) LENGTH TANK NO. INCHES OF WATER - BEFORE TEST__-a-- AFTER TEST---<a TANK LAyotrr TEST CAUSRATION P50 21 " = SIZE OF CAL BAR OR ML'S ADDED to (FACTT RA) S y l LINE MOVEMENT _ LINES LOAnrNG LINES r�Lfi i G2M 2 z So LINES 3 r 2 10 TOTAL 7- —LINES 3 = tid -�LINES 3 i END OF TEST CALIBRATION CSC7 -� SIZE OF CAL BAR OR MUS ADDED (aus) IFACiCR AI LINE MOVEMENT ,� LINES y 7 to LINES 3 I° LINES 3 =to LINES LINES ; 4 7CTAL (Aua) MEASURED API SPECIFIC GRAVITY PRODUCT TEMPERATURE (FROM TABLE A) API SPECIFIC GRAVITY W 600 F O � (FROM TABLE H) COEFFICIENT OF EXPANSION __R-a' (FACTOR 3) arEs � i lJrJ X ...vpL C;mANG1'F TA71K CAPACITY IGAI.) C.O= ADDITIONAL NOTES OR COMMENTS inhllC rya Dng B&Fcze- ioSt. �� � gy,57.;n1 Tc57crJ TiGh�' r DATA CHART FOR TANK SYSTEM TIGHTNESS TEST (EZY CHEK) _ PRODUCT MONMi R;NG ON LLR ProduG PRODUCT MONITORING IN S F. product TEIAPERATURE COMPENSATION NET VOL CHANGE Time Rung +Gain +Gairs +Gain X FaCvrJA +Gain Start -- End I + X radar B +-ion coon � 4 S.R {MiRay} Na. Stan I End Fa hx A Sort nd -lam -tea i I I I. f- I I I iI- ? I .p , f- 7 I I I i I- I-. I I I 7 f- s 1 �5 R:7 ( { 1 I I - - ' 947 I �I 9 f f 7 1 G l I I - 1. .2 17 c f I f I 9,-q,- q s l- 1 I I I 193U 1 :5 1 I 1 - 2� l , I i6 i I f p 2z. 1--037 7 o3 A. Tank Bot. to Grade Z73Send Report to: j��JD B. Tank Top to Grade y7 Client �Zs ePimitrx J c/c cc Zwc. GLADE C. Tank Diameter --�— Address.3/nAsS '�"useTrS ,9oe- D- Test Level above grade "�� City, State NORr I AVOO EA, Ai4. oiP�i5 E. Depth of water in tank 0 Phone(fig)GS3-313/ B G F. Depth for taking sample !/O Attn: B/i1 0'3,e1E1V F H G. Temp. Probe depth (connector) _ y7- " CEa+`T7RCA710N Ynis c rn unity mmi Uses tank system was scssea an tlate anwm.Those indieateC^Tigt:i•'meet Use citcria es=Iished 'iNE �!/F•�/�. �,�jJl7 /S A H. Test level to Tank Bot. �� by the Natior,Fre Protec on Fssoc awn Pamphier • f. Groundwater above tank bottom - G' �. J. Product Pressure per 1" height3/PSI Tank No_#Z c Tight ycs- ;s-'oo5 T WATER Test Pressure Formula Leakage indicated Az-, vOWmE DEPrH E i x_ x : 36 ) �^ Technician C.�ncAL-,u /,1cWZ M + NET T'G'T Date Tested ll C PRESSURE s 41, _ -- - - I I I i 3p Y a P 3B �. 1