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Data C' rt for Tank System Tight ss Test <br /> petro Tote <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ® <br /> Name Atltlraas •Repreeentanve <br /> Tank(s) � C Telephone <br /> Nem. Addrese Represemonlve Telephone <br /> 2. OPERATOR <br /> Name Addrm <br /> telephone <br /> 3. REASON FOR <br /> TEST F y <br /> (Explain Fully) f 14 17 <br /> 4. WHO REQUESTED <br /> TEST AND WHEN """e The comwnv or Afflllanon <br /> Dne <br /> Addleu <br /> Telephone <br /> 5. WHO IS PAYING /�� <br /> FOR THIS TEST? Comp.ny,A9.ncy or lndivitlual Person AuthoraInp <br /> Title Telephone <br /> Billing—unces City Sbt• Zip <br /> Anention ol: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED / ter, <br /> 4� o i <a S rA <br /> S rA f <br /> Location Cover Fills Vents Siphons Pumps <br /> 7. INSTALLATION (�JCSlc>F COrC2P�C �// ! <br /> DATA ,ZS/Fia4n / ! lQ13Mdle <br /> r3/ick!r�f a tiU Xao 3.1clia.,L- <br /> North inside tlrivawev, Concrete,Black Top. Sia•,Titefili make,Drop Suction,Remote, <br /> Hear of station,etc. EartM1,etc. rupee.Remota Fills Sia.,M.nifolded Which tanks? Make if known <br /> 8. UNDERGROUND 11-7,4 Is the water over the tank? <br /> WATER Depth to the Water table �� 11 <br /> Yes No <br /> 9. FILL-UP Tanks to be filled hr. Date Arranged by <br /> ARRANGEMENTS Extra product to"top Off"and run TSTT. How and who to provide? Consider NO Lead. Name , T.I.Phoha <br /> Terminal or other contact <br /> for notice Or inquiry - <br /> Company N.me Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, /! <br /> any other contractor <br /> involved <br /> 11. OTHER Lleiwo <br /> INFORMATION <br /> OR REMARKS <br /> Additional inlOrmation 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 /> Tests were made on the above tank systems in accordance with test procedures prescribed for Pier.—TITP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Data Tested <br /> This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the Nationaf,ElCa.Protection Asociation Pamphlet 329. <br /> Dau !L! 9... �:.�fii_G!c.• /—lr/ i.�sit.... <br /> -sum;Conimcbr or ComwnYBY� Si9naWrs <br /> Sepal No.of Thermal Tachniciana Address <br /> sensor a- <br />