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uata wnaoor i anK system iigntne I est <br />petro Tate <br />g- Jr %S TANK TESTER h -as-_ <br />Property MCA e V r <br />Name <br />Tank(s) <br />Name <br />OPERATOR <br />Name <br />3. REIFOR <br />TEST <br />(Explain Fully) <br />3 0 l l.U. Kt tr, <br />Address <br />Address <br />Address <br />STAYG �Qo-r 02 <br />/-(),0,' <br />Representative <br />Telephone <br />4. <br />WHO REQUESTED <br />CA e✓ ✓� <br />TEST AND WHEN <br />NaTe Title Company Company a Affiliation <br />Address Telephone <br />5. <br />WHO IS PAYING <br />be+�V <br />FOR THIS TEST? <br />CompilKi. Agency or Individual Person Authorizing Tine Telephone <br />Billing Address City State Zip <br />Attention of: Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />8,101 1/"- <br />/"-5>af <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />5; 7_11- 7­ <br />ow <br />7. <br />INSTALLATION <br />DATA <br />Location <br />4CI( q/� <br />s�Ar,�o,� <br />North Inside driveway, <br />of station, etc. <br />Cover <br />a5SO4aIt <br />CQve� <br />Concrete, Black Top. <br />Earth, etc. <br />Fills <br />3 ft or// <br />Size, Titsfill make, Drop <br />tubes, Remote Fills <br />Vents <br />�i/ <br />Size, Manifolded <br />Siphones <br />A , <br />/ (, <br />Which tanks 7 <br />Pumps <br />111hh <br />Suction, Remote, <br />Make If known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank T <br />Depth to the Water table t f: r1 ler Yes No <br />9. <br />PILE-UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by _ <br />- Name Telephone <br />Extra product to "top off" and run TSTT. HOW and who to provide? Consider NO lead. <br />Terminal or other contact <br />for notice or inquiry <br />Company Name Telephone <br />10. <br />CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />Sc o��- RoADc�uy Sty y,r <br />11. <br />OTHER <br />en' t r// ARS bec.v Cz,,,c•✓fe <br />INFORMATION <br />'F p Ym dk <br />OR REMARKS <br />Additionalinformation on any items above. Officials or others to be advised when testing is in progress or completed. Visitors or observers present <br />during test etc. <br />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for <br />atf0s detailed on attached test charts with results as follows: �TAP <br />Tank Identification Tight Leakage Indicated Date Tested <br />D' >.,/ yes - V, <br />This Is to certify that these tank systems wen to <br />13. CERTIFICATION the National Fla Protection Asoclation Pomphk <br />Dat//e�� <br />Seryl NO. of Thermal`in l Y Technicians <br />Sensor <br />'� ; ,: t • °$t �?• •'^'ate �gyyl:b' <br />