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� ..... .... —I ., .. . .y. ..— .....• <br /> petro Tite - <br /> PLEASE PRINT TANK TESTER AC y p , <br /> 1. OWNER Property ❑ 0 c o, <br /> Name AddNu Repenanreeva TNphoM <br /> Tenk(s) ❑ f O <br /> Name Add. Reeresantaeve T"laphone <br /> 2. OPERATOR <br /> Name AddNN TNawona <br /> 3. REASON FOR N L N S le ,-ole - t -tom 3 <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED � f < <3 «' <br /> TEST AND WHEN Nama - TNM wnv or Affiliatlw Data <br /> AddreN TNphe. <br /> 5. WHO IS PAYINGa soti <br /> FOR THIS TEST? Company.Agency or lm:114wl Pern AutMMng Ties Upgrades <br /> Billing Add. ON SYN Zip <br /> AMntion of: ONer No. Dep,Interactions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Aga St"I/Fiberglass <br /> 6. TANK(S) INVOLVED ^' U c 3 f '2S *�vi <br /> Location Cover Fills Vents SiphonH Pumps <br /> 7. INSTALLATION L_,o�-r Fr' cxx ' ccA 'Ife Zyr z " <br /> DATA of /taste Sr.< yy o 'J <br /> North inside driveway. Concrete,Black TO'. <br /> 'IN TiNlill make,prop Suction.Remote. <br /> Ren of mil etc. Faeh,nc. Thai Fllis Size.M.nllo,10 wNicn tanks? Make 11 kMwn <br /> 6. UNDERGROUND / Is the water over the tank? <br /> WATER Depth to the Water table 2� ❑ Yes No <br /> Tanks to be fined W hr. Date Arranged <br /> 9. FILL-UP Name TNepnone <br /> ARRANGEMENTS Extra product to"top ole"and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact D <br /> for notice or inquiry <br /> Company Tailspin.. <br /> 10. CONTRACTOR, cklil ilv to Ill.-eN <br /> MECHANICS, eai of r P 14 P2 ..a E <br /> any other contractor <br /> involved <br /> a"T <br /> 11. OTHER <br /> !T N <br /> INFORMATION f <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 /> TMs were mads on the above tank systems In soeordr nee with test procedures proscribed for eMro rnp <br /> 12. TEST RESULTS as detailed on attached test charts with rosues as follows: r f. <br /> Tank Identification Tight Leakage Indicated Data Tested <br /> w <br /> ra1 If. c Vital - <br /> Thi"la to clrrtny that[hese tank systems;were tested on the date(s)shown.Thole kMlcatetl n"TIgM"ttlNt the Ixitsrle sWbllshetl by <br /> 13. CERTIFICATION the National Fire Protection Asoclstion Pamphlet 329. <br /> 7-F 1 IC s �,DektZ i.l � c.��l � <br /> THdM ConuacYr m CpmwnYBv. Bigeetwe <br /> . �Lf' S. L /Ne-Ad Jt �� oc7c �o ,J <br /> Serial No of Thermal Technicians Address <br /> Senaw <br />