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TECH	Tech Name
	Date
CUSTOMER	Account #		Address
	Name		City		State	Choose AK AL AR AZ CA CO CT DC DE FL GA HI IA ID IL IN KS KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR RI SC SD TN TX UT VA VT WA WI WV WY	Zip Code
	TankSure Program	Warranty Tank Non-Warranty Tank
TANK INFO	Gauge Test Score	Distance From Wall =   Less than 2 inches Greater than 2 inches
	Tank Gauge:	10 12 14 Granby 20+		Un-sleeved Feed Line:					Yes No
	Feed Type:	Bottom Side Top		Feed Line in Concrete:					Yes No
	Tank Type:	Upright Flat		Exposed to Salt Water:					Yes No
	Capacity:	Gallons Litres		Seasonal Residence:					Yes No
	Manufacturer:	Unknown		Excessive Paint:					Yes No
	Year of Manufacture:	Unknown		OSV Valve (not Firomatic):					Yes No
	Signs of previous repairs or leakage?	Yes No		Proper Fill & Vent Pipe:					Yes No
	Location of Fill:			Vent Alarm Whistle:					Yes No
OUTSIDE TANK	On a Pad (If Outside)	Yes No	INSIDE TANK	Sump Pump:					Yes No
	Hazards (if Outside)	Yes No		Dirt Floor:					Yes No
	Hazard Comments:			Finished Basement:					Yes No
				Basement Condition:					Wet Dry
ULTRASONIC INFO	Status (First Year Tanks ONLY):	Qualified DQ'd Low Test Score		Location of Low Test:					Please Choose 1 2 3 4 5 6 7 8 9 10 11 12
	Reason For Disqualification
		Patching (Fiberglass, Magnet or Other)		Unstable/Rusted Tank Legs		More Than 550 Gallons
		Tank Is Leaking		Unstable Environment		Unable To Test Tank (Rusted/Unsmooth Surface)
		Failed Visual Inspection		Needs Vent Upgrade		Unable To Test Tank (Obstructed Access)
		Failed Ultrasonic Inspection		Underground		Unable To Test Tank (Inaccessible)
		General Comments
HEATING INFORMATION
	Equipment	Year Of Manufacture	Manufacturer	Model	Efficiency	Stack Temperature	Type	Energy	Necessary Repairs
	Boiler
	Furnace
	Heat Pump
	Fuel Savings Recommendations: Heat Manager/Controls Insulate Piping		Other Recommendations:				General Comments:
HOT H2O	Tank Oil Propane Electric Age: Manufacturer:
	Boiler Indirect Water Tank: Yes No
AC	Central Air Conditioning Yes No Repairs Required? Yes No Comments: