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I <br /> Data �- ..art fa) Wank System Tiglt-_,ess Test <br /> �T <br /> PLEASE PRINT <br /> 1. OWNER Propany C Qr4l�el(�1 /� f/Lfr�c.o�� t <br /> Na <br /> ddrsp aror nun.. T non. <br /> Tankle) aron mudp TaNahona <br /> Ibme Aedlpr <br /> 2. OPERATOR a.m. rDt Adders, Td•p^°^• <br /> 3. REASON FOR greet aj g.& w <br /> TEST <br /> I Explain Fully) I <br /> 4. WHO REQUESTEDNem. . 'Tins t:emgny or AlttlMtlon Data <br /> TEST AND WHEN <br /> Add. Tdphone <br /> 5. WHO IS PAYING tomwnG Aepwer tnelaMual tenon Aeaeda np rte Talpnona <br /> FOR THIS TESTI - <br /> s <br /> e11nMAedres, ----..—._-- city Son Zip <br /> Attehtlorl of: ONer Ne. Dew Iwlrecllona <br /> Direction Strol/Fibarplep <br /> I ntify by Appoint.Ae <br /> 6. TANK(S) INVOLVED <br /> Location Cover Fills Vams Siphonp Pumps <br /> 7. INSTALLATION <br /> DATA c� -L_ �9��t, } 2�� r%y// /Vo✓� S {tin <br /> se,of st drNewp. C°ncrE."Slack Top. Size.TlNipl m.ke.Dmp Suction.Ramole. <br /> apr M aNMon,.tc. Eann, M. tubp.Remote RIIIr Sl&a.ManaoMae <br /> Which Nnka? Make it Mrown <br /> B. UNDERGROUND F r l&the water over the tank? <br /> WATER Depth to the W~taw y L1 yes No <br /> Tanks to be filled V,0+ hr. Dan Arranged by 1 <br /> 9. FILL-UP Ism. Telephone <br /> ARRANGEMENTS Extra Product to"top off"and run TSTT. How and Who to provide? Consider NO Lead. <br /> Terminal ptnMr comact —for notice or inquiry <br /> Cpmppy Nama Telephone <br /> 10. CONTRACTOR, 42t� <br /> MECHANICS, <br /> any other eont"aw --- -- <br /> involved --- <br /> 11. OTHER A,eal LI- <br /> INFORMATION <br /> OR REMARKS <br /> Additional Information on any Items above.Official&or others W be advised when testing n in proprep or completed.Vishors er observers present <br /> during test etc. <br /> Teats wero made on the above tank systems in accordance with teat procedures prescribed for DMre TI� <br /> 12. .TEST RESULTS as detailed on attached feet charts with results as follows: <br /> n1d*nti'",ion Tight Laek°ge Indite ed Date Tested <br /> This Is to certify that thew tank systems were tested on the date($)shown.Those Indicated as"Tight"meat the criteria a ablished by <br /> 13. CERTIFICATIO DID pagonall JFln Protection A dation Pamphlet 329. <br /> Do <br /> / Z 7 V / r 1>ani�a c ro�o�c mp a W...Said Nor.or Thermal acn kla s 6 / - J /--- <br /> A°°re <br /> aerlaer, <br />