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Data uzirt Tor IanK aySIUM I11gnvAcsa 1001 <br /> petro Tde <br /> PLEASE PRINT TAN <br /> K TESTE <br /> 1. OWNER Property jjj:g1wFISftT <br /> Neer. Address bpnaenmlra Telaplians. <br /> Tank(&),® <br /> Name Addres Repnwmnrrs Tolophorhor <br /> 2. OPERATOR eemeH F S Addrma telephone <br /> 3. REASON FOR AINUAl 1rf &wVr <br /> TEST <br /> lEaplain Fully) <br /> 4. WHO REQUESTED zeiry ees <br /> Tl <br /> TEST AND WHEN Title ComwnY or AHdxuon Del. <br /> Address Talephene <br /> 5. WHO IS PAYING 4 pIte �/ 913 kSGG / <br /> FOR THIS TEST? A nc ndy duel Person Authorising Tide Telephone <br /> U Ef Co re ele7e N O.: <br /> Bnling Address City Sul. ZIP <br /> Attention of: Order No, Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Appros,Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED o 1 Sf� L <br /> ap7 NaYaI� & do L5rft <br /> Locatione Cover Fiils� II FiuS Vents S i Siphones Pumps <br /> 7. INSTALLATION �cjD✓r cQEq' led z7 'f� e Af <br /> DATA I <br /> ��jt"'a' dR TvlacS G lo^ SC[tT�C <br /> Qiar nr�p+r Al2f rrlAvt(�, <br /> NoJh.We drirsway, Concrete.Black Top. SM6,Tltefill mate,Drop Suction.Remote <br /> Pear oesradon.eta Earth,etc. tubes.Remove Fills Sue,Manilolded Which ranksMake If known <br /> B. UNDERGROUNDrzrz Is the water over the tank? <br /> WATER Depth to the Water table,.a24x W Ii1 N'P i3C y E��-r�G,f/ Yes �No <br /> Tanks to be filled QTCU) hr. :r ffL3 Date Arranged by RIDN 'e fyfR C <br /> 9. FILL-UP Neme Tslepnone <br /> ARRANGEMENTS Estra product to"top off"and run TSTT. How and who to provide 7 Consider NO Load. <br /> Terminal or other contact <br /> for notice or inquiry <br /> CDmptnY Name TaleDhoM <br /> 10. CONTRACTOR, — <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any hams sold".Officials or other to be edri"d when testing Is in progress or completed.Visitors of observers present <br /> during lest etc. <br /> Tests wan"do on the abo"tank systems In accordance with test procedures prewebed for aarolro dip <br /> 12. TEST RESULTS as daulled on attached test chane with results as follows: <br /> Tank Identification Tight leakage Indicated Dne Totted <br /> U — •P _=�_S�ZfZ <br /> 4 S –r <br /> This N to eatlfy that these tank systema wen tested on ted dates)shown.Those IfldtCaleA N' 41rit"meet the Mata*sU**ObW by <br /> 13. CERTIFICATION the Netlonal Fin Protection Aeoctatlon Pamphlet Jog. <br /> IAA3%cmlt NQRTHCAL CONSTRUCTION � <br /> SG " - Post Offl ']fLi roti er omwnr. s-. _ —lax <br /> I MrrllNa MTnrmM v'si sem ___.. Stocktom,��� i��—_�Aeoxea <br /> elenpr <br /> e <br />