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Data r part for Tank System Tightness Test <br /> petro utp <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Properly ❑ 4E / hyo ck <br /> ❑ Name Addtass pepwaamalive Telephone <br /> Tanks) N LL f �.f• —/ <br /> Nema Address Representative T.I.Phone <br /> 2. OPERATOR C 8; de o <br /> Name Address Telephone <br /> 3. REASON FOR u v <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED e A T� ts`r < <br /> TEST AND WHEN Nem < Title Compsnyor Al lisaon Date <br /> N r N < Y 2- // IN ry <br /> ` Address Telephone <br /> 5. WHO IS PAYING < ' n c .J <br /> FOR THIS TEST? company.Agency or roameual Person Authorizing Tide Telephone <br /> Billing Address city Sul. zip <br /> Attention ot: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplie, Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED -/- -r �_ o 0;r Sr C 3 o HF L <br /> 4"' -& �V_ 5 X 0 (clerfA IQ 2o r tee <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION yyrr ie d <br /> DATA <br /> fJ C,.•t�. <br /> North Inside driveway, Concrete.Black Top. Site,Titelill make.Drop Suctlon.Remote. <br /> Rear of atnIon,etc. Earth,etc. tubes,Remote Fills Size,Manlfolded Which tanks 1 Make it known <br /> 8. UNDERGROUND /p �•�„ Is the water over the tank <br /> I��l o <br /> WATER Depth to the Water table tJ ❑ Yes No <br /> Tanks to be filled hr. Data Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide i Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry / � L [ ON <br /> Company Name Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <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 /> Testa were made on the above tank systems in accordance with teat procedures prescribed for tro jl}P <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: r.—Mm— <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> y''w O <br /> Sw 2 1 o / _ / - ,fi> <br /> This is to certify that these tank systems were tested on the date(s)shown.Those Indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the is <br /> Fire Protection Asoclation Pamphlet 329. <br /> Sf-cic-le•.. 11ct-r�r✓ �-Z�.— <br /> DN° Toting Contiaotor or Company. By+ Sign.mre <br /> Serial No.of Thermal Tankm Address <br /> Sensor <br />