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<br />10. OTHER
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<br />OR REMARKS
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<br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present during test. etc.
<br />11. TEST RESULTS
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<br />North inside driveway,
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<br />INFORMATION
<br />OR REMARKS
<br />6
<br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present during test. etc.
<br />11. TEST RESULTS
<br />Tests were made on the above tank systems In accordance with test procedures prescribed for
<br />as detailed on attached test charts with results as follows,.
<br />Tank Identification Tight Leakage Indicated
<br />Date Tested
<br />4s
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<br />3. REASON FOR
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<br />4. WHO REQUESTEDD
<br />TEST AND WHEN
<br />Data Chart for Tank Systciin Tightness Test
<br />PLEASE PRINT
<br />1. OWNER Property
<br />Tank(s)
<br />/1/ f2 Ti' �O T Sur , 1' v 2 i UE j U C�ql 6 �7oS
<br />Name _ Address Representative
<br />n a Z
<br />Name Address Representative .;';I�O��ii�„�;_iT�te t3oge;.,�1--•.
<br />2. OPERATOR
<br />OPERATOR
<br />n n u 3>
<br />Name Address
<br />Telephone•
<br />3. REASON FOR
<br />TEST
<br />(Explain Fully)
<br />&VII& IV 9
<br />4. WHO REQUESTEDD
<br />TEST AND WHEN
<br />V
<br />T Name Title Company or Affiliation
<br />O
<br />Address
<br />Telephone
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<br />S
<br />Capacity Brand7Suppllef
<br />Q4 Y-
<br />Grade
<br />(wZ2=�
<br />Approx. Age
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<br />6. INSTALLATION
<br />DATA
<br />Location
<br />l� przr✓.� ✓,vii
<br />North inside driveway,
<br />Rear of station, etc.
<br />Cover Fills / / �/
<br />f1I 4,C , fly
<br />Concrete. Black Top, Size. Ttelili make. Drop
<br />Earth, etc. tubes, Remote Fitts
<br />Vents
<br />it
<br />Size, Manlfolded
<br />Siphones
<br />Which tanks?
<br />Data Chart for Tank Systciin Tightness Test
<br />PLEASE PRINT
<br />1. OWNER Property
<br />Tank(s)
<br />/1/ f2 Ti' �O T Sur , 1' v 2 i UE j U C�ql 6 �7oS
<br />Name _ Address Representative
<br />Telephone
<br />Name Address Representative .;';I�O��ii�„�;_iT�te t3oge;.,�1--•.
<br />2. OPERATOR
<br />OPERATOR
<br />— G o DSEN� _ a
<br />Name Address
<br />Telephone•
<br />3. REASON FOR
<br />TEST
<br />(Explain Fully)
<br />&VII& IV 9
<br />4. WHO REQUESTEDD
<br />TEST AND WHEN
<br />I�`fi � r�� ACTS X12 - f�y d/'D COA/err�rcr
<br />T Name Title Company or Affiliation
<br />Date
<br />Address
<br />Telephone
<br />5. TANK INVOLVED
<br />Use additional lines
<br />for manifolded tanks
<br />Identify by Direction
<br />S
<br />Capacity Brand7Suppllef
<br />Q4 Y-
<br />Grade
<br />(wZ2=�
<br />Approx. Age
<br />Steel/Fiberglass
<br />L
<br />6. INSTALLATION
<br />DATA
<br />Location
<br />l� przr✓.� ✓,vii
<br />North inside driveway,
<br />Rear of station, etc.
<br />Cover Fills / / �/
<br />f1I 4,C , fly
<br />Concrete. Black Top, Size. Ttelili make. Drop
<br />Earth, etc. tubes, Remote Fitts
<br />Vents
<br />it
<br />Size, Manlfolded
<br />Siphones
<br />Which tanks?
<br />Pumps
<br />Suction. Remote,
<br />Make if known
<br />7. UNDERGROUND
<br />WATER
<br />Is the water over
<br />Depth to the Water table / ❑ Yes
<br />Tanks to be fille4 hr. �J �1 �' Date Arranged by
<br />Name
<br />Extra product to 'top off' and run tank tester. How and who to provide? Consider NO Lead.
<br />the tank?
<br />❑ No ,1
<br />Telephone
<br />8. FILL -UP
<br />ARRANGEMENTS
<br />Terminal or other contact ������0
<br />for notice or inquiry
<br />-- -- --- - --
<br />Company Name
<br />Telephone
<br />9. CONTRACTOR,
<br />MECHANICS,
<br />any other contractor
<br />involved
<br />-
<br />-
<br />10. OTHER
<br />INFORMATION
<br />OR REMARKS
<br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present during test. etc.
<br />11. TEST RESULTS
<br />Tests were made on the above tank systems In accordance with test procedures prescribed for
<br />as detailed on attached test charts with results as follows,.
<br />Tank Identification Tight Leakage Indicated
<br />Date Tested
<br />4s
<br />12. SENSOR 13. This Is to certify that these tank systems were tested on the date(*) shown. Those Indicated as "Tight” meet the criteria established by the
<br />CERTIFICATION National Fire Lection Association Pamphlet 329.
<br />chnicran
<br />Date
<br />(� Testing Contractor or Company. By: Signature
<br />Serial Neof Thermal CB c n e ' ` .'/v _
<br />Sensor
<br />Address
<br />Certification rx r ! fr°' PN6827
<br />3
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