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Dataf�rt for Tank System Tig mess Test AJC . <br /> petro Tate <br /> • PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ O t0 C_h--Name e.. Is Telephone <br /> Tank(s) of 1 ( 1 <br /> Nems Address Ralosenlodvo Telephone <br /> 2. OPERATOR L <br /> Nam. ' Address Telephone <br /> 3. REASON FOR °✓ t e.a c A. /c e, b<J <br /> TEST <br /> (Explain Fully) <br /> 4, WHO REQUESTED {{ 7 0"' 9-`T � <br /> TEST AND WHEN Name Titl. Lo pa4:aA letlon Data <br /> More. Telephone <br /> 5. WHO IS PAYING ec e ✓ <br /> FOR THIS TESTI Company.ApancY or Individual Person Authorhing TitleTelephone <br /> Billing Address Clty State Zip <br /> Attention of: Order No. Me,Instructions <br /> Identity by Direction Capacity Brand/Supplier Grade Approx.Age Steel/FibugWs <br /> 6. TANK(S) INVOLVED o r .2 t*- Be L <br /> o04_ SSo ieev 74jbt i <br /> Location Cover Fills Vents Sipholtes Pumps <br /> 7. INSTALLATION .F I r,- C Pot` <br /> DATA OF <br /> 9 1 0 Ne;.fJ <br /> �:re <br /> He-56 <br /> Nonh Imide driveway, Concrete,Block Top. Size,Titeall seeks.Drop Suction.Remote, <br /> Ren of surtion,etc. Earth.etc. tulles,Remote F&Is She.Mendolded Which ton"? Meke it known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table Q e lo,_i, /a ❑ Yes 2 No <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. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company We. Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER A 1 E 0 . > c 0 <br /> INFORMATION 11 - 0 0 Q Or n 2its <br /> OR REMARKS <br /> Additional information on any items above.Officials at 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 onro <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: %taro TI}P <br /> Tank Identification Tight Leakage Indicated Date Tasted <br /> S <br /> f� rAj e7H <br /> This Is to certify that these tank systems were tested on the date(&)shown.Those indicated as"Tight"most the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. �/ <br /> 7, 9 -Ire Jcrr� cAI ' f F;I ( of ctor,tfil Lro�/t— /• 7� <- <br /> yDue <br /> lS S2Tesanp Cpnaedor or Com av rime <br /> IYaS �. CDdd,a. Sf <br /> Ser1el No.of Thermal Techniclana M res <br /> Sanaa <br />