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� <br />. . . .. .-.; <br />UNDERGROCJND STORAGE TANK � <br />. � YL. . <br />=�-=-TigMness Testing Checklist " <br />...,r:.r�;, - -- ---. .... . . <br />�?i��cr <br />The purpau oC this form is to certiCy the proper iighiness tcsting oC underground smrage tank (USTj systemd inUuding <br />conneaing underground piping. Tightncss trsting shall be mnductul in accnrdana with Chapter 173360 WAG <br />'Ihis Ttghtncss Trsting Cttecklist shall be mmpleted and signed by a Ilcensed'C[�htnrss Trst(n� SupecvL+or. T'he supervi. <br />sorshall bc on sitc whcn all tank tighlncss tcsting activiti� arc hcing mnductcd. Thc firm which cmpluys thc liccascd . <br />supecviwr�hall aLso bc 6cerucd by the Wachingcon Statc Dcpanmcnt oCEmlo� u a Smlce Yrovider. <br />Underground storage tank rulcs require owners/opecators to cmploy a licensed tank scrvias providcr to rcpair, rcplaa,• . <br />upgrade, or close the UST system and ro begin corrective aaion in accordancc �vith WAC 173-360-399 iithe test results ' <br />indicate that a Icak cxists <br />For [urther in[ormation abou[ comnleQng this form, please wntacc the Depanmeru of Ecotogy UST Progcam. ` <br />Aseparate che�lclist must be complet� Cor each UST system (tank and auodated piping) tightnm tated, aactptthat <br />upante US'I'systemc tightness tested at one site may be reported toge[her by complcting page 2 a[ t6is [ormxparatUy <br />Cor wch system T'he completed checklist should be mailai to the [oilowing addrex; wit6in 30 days aCmmpledon oCdght- <br />n�a testin � .. _: -- - — --- --�� • -- <br />� .. _ . . . _�..�. . _ . . . .. - � Undergraund e enk -. _ �.• i ; • � ,. <br />. .. _ . Departmerrt d Etobpy .- - --.. _ __ . ..... _ ... . . . - - <br />- -.• - --• ______ . . ._. ._ MaII Stop PV-11 - <br />, . oNma�.wnseso48nt .. ... , _.._.::..,' <br />I• _-=- ---._._. ._. . ._ _._. ._ -.--. _ . .. . _._.-...._ --•---•---_••-- — <br />� .. ..5; YSTE QN/NE ,. _ . OCATION . ..... . .-.. •.1 .. .. ,,. � , . . <br />IUSTOwne:/Operator. . _ ... ;... �..�._;._. <br />I Owneis Address: . . . _ .. _... . _ .. . _ -- ..` _ � .. . , -. -----. � - _ . <br />..; . <br />� ' � . . .. � :.>• .. s.�.;r•�.;,,. . j•� <br />, '�' �'�" -- - ---.. �. . arur....�._,-.: .:+.. - <br />.:_-- ---' -.. .._. ... . �- -- ' ' - • - - • . . .:n:.i.; .. ..:.eii:ai� :LI: .� <br />TB�Bpf10f1B: . . . � � � � ' ' . .. .. . . . .. . . .. � ' <br />i . , ." . . . ' ' ' . • . ' . .,a...._.'N .( <br />. . . .. . .... : <br />. � <br />. . . � <br />sae In Numbec (on Imroice ar. aveilabla from Ecdogy � tank b regisierecf): ... . . . . _ _ _ :-t � .. <br />Sfta/8uslness Name: • �%Z�l�f%—• �.�'/l� ���1 /a i✓ �s , , - <br />�.. __. n. . _,- <br />... . ._-. . .... _. <br />SMB Add�esx ��'p'U" � �Y��/ ��!%1i � �z /�e7y! /�/hG ,,:: v: <br />' � . � � <br />��/�iY�— [�/�- ' .,-.. ,' <br />. . an . . • a.. mca" . . . . � . i.- <br />I+Z,_1'�1lCa_-�tt�l,;�`Itaa[��ca��u;r��n_r,.,vn_mcu�o�,i'�'=;r;,�`.".':;:.". <br />ptmL _ ...... .. SME COCtP.ORATLON. --- -- ...- -- <br />� <br />. _. ..-- <br />.... �- •. ucensa humaer: C � 0 0 6 4 ---- -- ` <br />- ---_----------^�- - <br />� qddress ------ - -Z3'0 Z aC"S'�' :- ---- •-. . ..A_ ._ �. ------ — • .. <br />� c„„ �.n r � i <br />TA��tdA ItiASHINGTON . • 98402.. .._.._:__�....- <br />f. . c� . .. .. .. . a,,. - <br />� Taeph«,a: . I ) - --........ <br />--.t-�- <br />� Llceroed Supervh�or: c��/�s��,�/ L cerue Nurt�b�e .�1Lrz%`G'- I� -. <br />earo,s,s nNv pe�7. t <br />