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%ata Chart for Tank Syseern Tightness Test <br /> PLEASE PRINT <br /> 1. OWNER property X �^ r oAj _ <br /> Tanks) Name Address Representative Telephone <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4, WHO REQUESTEDS14A,' C? <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Telephone <br /> - Identity by Direction Capacity Brand/Supplier Grade Approx.Age SteeVFiberglass <br /> 5. TANK INVOLVED &Ce <br /> Use additional lines - <br /> for marnfolded tanks - <br /> Location Cover Fills ver is Siphons Pumps <br /> 6. INSTALLATION <br /> DATA 70 /le /VrJ /�rincr it <br /> North inside driveway, Concrete,Black Top, Size.Titefill make,Drop Suction,Remote, <br /> Rear of station,etc. Earth,etc. tubes,Remote Fills Size,Manifelded which tanks? Make 1 known <br /> 7. UNDERGROUND ��� Is the water over the tank? <br /> WATER Depth to the water table Ryes ❑No <br /> Tanks to be tilled hr. Date Arranged by <br /> 8. FALL-UP Name Telephone <br /> ARRANGEMENTS Extra product to'lop off'and run tank tester. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, < ` <br /> any other contractor <br /> involved <br /> 10. OTHER 7 A.rJ <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 during test,eto. <br /> Tests were made on the above tank systems In accordance with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> 12. SENSOR 10.This Is to certify that these tank systems wETe tested on the date(s)shown.Those Indicated as"'Tight"meet the criteria established by the <br /> CERTIFICATION National Fire Protection Association Pamphlet 329. <br /> echnicians <br /> Data <br /> Testing Contractor or Company. 9y: Signature <br /> Serial No.of Thermal Cenitication• ��� 7i <br /> Sensor / / �L .!? ,*? st <br /> Address <br /> Certification o PN6627 <br />