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Data * <br />PLEASE PRINT <br />for Tank System <br />petro TIte <br />TANK TESTER <br />Tigh#ss Test <br />1. <br />OWNER Property <br />Clle_vro-ti D.1 <br />Tank(s) L1Name <br />Address Representative <br />Telephone <br />Name Address <br />Telephone <br />2. <br />OPERATOR <br />/Representative <br />301k�/c.+,u, �OML Got�i (—olid. r �iw, <br />Name Address <br />ielephone <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Name Title Company or Affiliation <br />Date <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />FOR THIS TEST? <br />Company, Agency or Individual Person Authorizing Title <br />Telephone <br />Billing Address City State <br />Zip <br />Attention of : Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />#Sou-fk <br />0000 <br />Aev <br />U.4 le. <br />1-15,eI los <br />".3' O�'%� <br />�OOG�C7 <br />�1Lv�e..1, <br />c Nl.lr• <br />, ♦r <br />7. <br />DATA INSTALLATION <br />Location <br />Gv�sfs;� <br />d� <br />North insidedriveway, <br />Rear of station, etc. <br />Cover <br />o-Cro <br />C <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />. X/ "IC <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Vents <br />'� <br />Size, Manifolded <br />Siphones <br />�- <br />Which tanks? <br />Pumps <br />sac.IL,o.n, <br />Suction, Remote, <br />Make if known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank? <br />D7,th to the water t bie /31_5�b { 2/o" 6,."4-,o „ Yes No <br />�. 33 " cP <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name <br />Extra product to "top off" and run TSTT. How and who to provide 7 Consider NO Lead. <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />10. <br />CONTRACTOR, <br />$�a^A 0-7eva a0'' Owe. Ca,,,! /,? "1)foo-k <br />MECHANICS, <br />any other contractor <br />involved <br />11. <br />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 <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 "--ro TIte <br />as detailed on attached test charts with results as follows: TANK TWER <br />Tank Identification Tight Leakage Indicated Date Tested <br />e s '017 6. P. N, <br />9_ - Ne, <br />R <br />1-3 i Yc — oa / �� y. <br />17-1-1661 <br />13. <br />CERTIFICATION <br />This is to certify that these tank systems were tested on the lets Shown. Those indicted as <br />the National Fire Protection Asociation Pamohlet 329. \ 1 <br />"Tight" Bet the criteria established by <br />Date <br />Serial No. of Thermal <br />Sensor <br />trM (fAr15Ac'tSC.A, <br />Technicians <br />