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• r 111l011t1 4110111 IUI IPQ'troTIPn a syna+EU00 surestp vhf/ <br /> ► [ASC PRINT �../ 1ANK TESTERl�/O�V <br /> waste <br /> 1. OWNER Property ❑ { `Ly1�NUi�1 CTG141L1 G I�S 'el > �• C/Vil h'T�IE" �V E L rV r/fjr* / <br /> Name Addr•ak Re Dra.•melrr• Telephone <br /> Tank(s) <br /> Name Addran Repn•entnrve TeNphOM <br /> 2. OPERATOR AC/+ MING f <br /> H•m• Addn%, Telephone <br /> 3. REASON FOR F <br /> TEST <br /> (E.Plaln Fully) .. <br /> 4. WHO REQUESTED 0 te,At, KAAI G' <br /> TEST AND WHEN tame Title Company or Affiliation Dare <br /> C WI GFN <br /> Address LleDanne <br /> 5. WHO IS PAYING A7 G <br /> FOR THIS TEST? Company.Agency or Indnitluel Pinson Autam in Tide Telephone <br /> e • <br /> siginp Address City sura Zip <br /> Attention or: Order No. Other Instructions <br /> Identify by Direction Ce achy_.- Br Supplier _. _Gr • -..:_Approx.Ape _ . . Steel/Fiberpleu_ <br /> 6. TANK(S) INVOLVED f 1➢ ¢� )S- xreei <br /> Location a t� Cover Fills Vents Siphones Pumps <br /> y tiOQfhi IIFr e r r �,i / rrvf y <br /> 7. INSTALLATION �- i N-'ti <br /> DATA ef.r;ecw4o ale Cpaere. ' y SvCfra" <br /> tr r ;e` 5/6fF• % 57NI/� /rfvc t.1011.� OvMF <br /> Nona f 1 s tlri *I,. Cone for pock Top. she.Thafin make.Drop SMake i Remota, <br /> Fear of atnion,Ne. Gana,etc. tubes.Remote Fllh Sias.Manllolded Which cants? Maka it known <br /> S. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water <br /> rttrabble.A p (.0 �eeT ❑ Yes No <br /> Tanks to be filled t., /a/�Date Arranged by 00,04R1/1,`�1 <br /> 9. FILL-UP Nsme Telephone <br /> ARRANGEMENTS i product to"top off'and run TSTT. Now and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company N•m• Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS. <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> AddrGonol information on any items above.Olficials or others to be advised when testing is in progress or completed.Visitors or observers praaeni <br /> during test etc. <br /> Tots were made on the above tank systems In accordance with test procedures pnseribed for .fo Tate <br /> 12. TEST RESULTS as detailed on attached total Mans with results o follows: <br /> INI <br /> Tank Identification Tight Looks a Indicated Data Tested <br /> t s .5 —. N <br /> This Is to canny that thoe tank systems were tooled on its date(&)shown.Those Indicated as"Tight'melt Mea ale established by <br /> 13. CERTIFICATION the National Fin Protection Ai oclation Pamphlet JI <br /> I��� tfii "1` NOMI•I CAL (:OWItUeTIaN <br /> Dar. office Box 598 <br /> ��'"Itf or Com pen• a. can rs <br /> r <br /> oryol Nu el Tier., •�hMr,ar,� Addrerr <br /> Muco <br />