Fascility Name :

Address :

4023 W. Sample St.

City, State, Zip Code:

South Bend, Indiana, 46619

Fascility Id :

2807

Testing Company:

Petroleum Testing(PTS)

Owner:

GPM EMPIRE, LLC

Address :

City, State, Zip Code:

, , 23227

Phone :

(574) 532-7858

Phone :

Date :

Tank Number	Tank 1	Tank 2	Tank 3	Tank 4
Product Stored
Spill Bucket Capacity
Manufacturer
Construction	Single-walled Double-walled	Single-walled Double-walled	Single-walled Double-walled	Single-walled Double-walled
Test Type	Hydrostatic Vacuum Single-walled Double-walled	Hydrostatic Vacuum Single-walled Double-walled	Hydrostatic Vacuum Single-walled Double-walled	Hydrostatic Vacuum Single-walled Double-walled
Spill Bucket Type	Product Vapor	Product Vapor	Product Vapor	Product Vapor
Liquid and debris removed from spill bucket?*	Yes No	Yes No	Yes No	Yes No
Visual Inspection (No cracks, loose parts or separation of the bucket from the fill pipe.)	Pass Fail	Pass Fail	Pass Fail	Pass Fail
Tank riser cap included in test?	Yes No NA	Yes No NA	Yes No NA	Yes No NA
Drain valve included in test?	Yes No NA	Yes No NA	Yes No NA	Yes No NA
Starting Level
Test Start Time
Ending Level
Test End Time
Test Period
Level Change
Test Results	Pass Fail	Pass Fail	Pass Fail	Pass Fail

Comments :

Tester's Name (print):