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Information
1 Name of Tank Owner or Operator
Address
Reason for Test (please check) Type of Test Used (please check)
2 New or altered or repaired system set into operation
3 Hydrostatic (Underground systems)
Request from Department 48 hour dip (aboveground vertical systems)
System being abandoned Visual (Overhead Horizontal Tanks)
Storage Tank System in critical area Pressure (Piping Systems)
Storage Tank System in sensitive area Electrical Potential (Cathodic Protection Systems)
Other (specify) Percolation (Dyking Systems)
Other (specify)
Information
4 Attach a sketch of all storage tank systems at location, indicating which systems were tested.
mV
C. Result (B/A):
I / We certify that the information supplied on this form is complete and accurate.