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Data Ctt„t for Tank System T€ght._ ss Test <br /> pc%firO Tote <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Pnpeny [� — <br /> O Name 9V C�f4 Azriron — mativs - -- <br /> ank s V •,�, 0 Repreaa <br /> f r Tslaphona <br /> T <br /> Name Arizonas Representative TelapM1one <br /> 2. OPERATOR <br /> - Neme Address Telapnone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> t <br /> 4. WHO REQUESTED i <br /> TEST AND WHEN Name Title Company or Affiliation Daro <br /> Adorns Tebohone _. <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Ag ency or Individual Person Authorizing Title Telephone <br /> Billing Address city slow Zp <br /> Attention of: Order No. Other Instruction <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED <br /> Location Cover Fills Vents Siphonn Pumps <br /> 7. INSTALLATION oAce oAe <br /> DATA /t <br /> North Fea inside driveway. Concrete.Black Top. Size, es,Remote <br /> make.Drop Suction,Remora. <br /> Rear of station,etc Eanh,am, tubas,Remote Fills size,Menlroltled WM1icM1 unka i Mab N known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table Yes No <br /> � D <br /> t <br /> Tanks to be filled -hr. Date Arranged by ` <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide? Consider NO Lead. G <br /> Terminal or other contact i <br /> for notice or inquiry r <br /> Company Name TelapM1one ) <br /> 10. CONTRACTOR, <br /> MECHANICS, 7c'^ ^curE <br /> any other contractor <br /> involved <br /> 11. OTHER 4 611IA- Z/a u / <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 /> Tests were made on the above tank systems in accordance with test procedures prescribed for Petro Tlt! <br /> 12. TEST RESULTS as detailed on attached test charts with reso !I —nura <br /> Tank Identification Tight eakage Indicated Date Tested <br /> A 47 is- 4 f? -96 r <br /> UNy flf-ir +` <br /> On ho <br /> This is to certify that these tank systems were tel on the dates)shown.Th indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet <br /> ?' <br /> Date TeStinp nbactor or 6ompany. or: big..Wra <br /> Senal No.of Thl Technicians Atldreaf <br /> ena <br /> Sensor ., / ' ' <br />