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r <br /> Data Chart for Tank System Tightness Test <br /> petro Tde <br /> PLEASE PRINT TANK NESTER <br /> 1 <br /> I. OWNER Property [El,- ' f :-.'� a 7_/�11iP, �7�8E"! %d k� <br /> Tank(s) Name Address 1 RaPresmnliv Telephone <br /> Name Addlrss Rspresentah's T@1e0hone <br /> 2. OPERATOR 71�^ <br /> Name Address Telephone <br /> 3. REASON FOR' <br /> TEST <br /> (Explain Fully) - <br /> 4. WHO REQUESTED <br /> TEST AND WHEN N'm' Title Company or Allllialion Date <br /> Address telaphon• <br /> s. WHO t5 PAYING 77 <br /> FOR THIS TEST? Company.Agency or Individual Person Aulhodaing TI1I• Telrphohe <br /> string Address City Slate Zip <br /> Attention of: Order No. Other Instructions <br /> Idontily by Direction Capacity Brand/Suppliar Grade Approx.Age Steal/Fiberglass <br /> 6. TANK(S) INVOLVED Zz% " i <br /> Location Cover Fills Vents Siphones Pumps <br /> 7 DATAALLATION Ile /I /Ik j` <br /> North insure driveway. ConW@te.aiaek Top. Sit@,titefill melee,Orop Suellen.Remora. <br /> Rose e1 station,eta Eertn.etc. lubes.Bernois Fills Site.Menilolded which tanks?' Make it known <br /> 8. UNDERGROUND Is 1 h water over the lank 1 <br /> WATER Depth to the Water table Yes No <br /> Tanks to be filled hr.. Date Arranged by <br /> 9. FILL-UP Nim• Ydeohen• <br /> ARRANGEMENTS 'Extra product to"top oft'and rue TSTT. Now and who to Provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Camoeny 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 ate. <br /> Tests were made on the above tank systems in eecordance with test procedures prescribed for IIP <br /> 12. TEST RESULTS as detailed on attached lest charts with results as follows: ft7 <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> 1; C <br /> 13. CERTIFICATION This Is to certify that these tank systems were tasted an the dates)shown.Those indleated as"Tight'meet the criteria established by <br /> the National Fire Protection Asociation Pamphlet 329. <br /> Dale Lawrence Tank Testinury .V//� <br /> _ �7 <br /> RO. Box 407 By: S <br /> Sonat No.of Thermal 7lehnrersne Downieville,California 95936 (916) 289-3109 <br /> Senna <br />