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L.B.M.E. CORPOR.ATIONo <br /> Oetroleum Testing and Monitoring PPFT`O Tifif <br /> Data 'Cert for Tank_ System Tightness Test t` TANK TESTER <br /> 1. OWNER property <br /> �r Nam. 0 ,r pcpr rn INS Telephone <br /> Tank s �( �J l�11 iY/ <br /> Name Address Aepiesentaliye Telephone <br /> 2. OPERATOR �1G/�/� �L OS/ c ,✓ �Tnc TOa/e C'�. <br /> Name V16 Al 7 Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) s <br /> 4. WHO REOUESTED <br /> TEST AND WHEN Name Title Company of Attilistlon Date <br /> Address T.leohone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Agency or Individual Person AuthorialIno Title Telephone <br /> Billing Address City SUI■ IIP <br /> r ' <br /> Atlentlon at: Order No. Other lnslructlons <br /> Idenliiy by Direction Capacity Brand/Supplier Grad Approx.Ape Steel/Fiberplass <br /> 6. TANK(S) INVOLVED > Dom '. zqcr <br /> LocaIy n Cover Fills Vents Siphons Pump <br /> 7. INSTALLATION Wit/©•CST_ / / <br /> DATA pF"4'L1.'!!. : y� Z�' / ,�1G►T <br /> North imide drlveway. Concrete.Bleck Too. Sire,Thelln make,Drop Suellen.Aemon. <br /> Rear.1 are bnw,.Ice [cath,ere. lune.,Clamor.Fills SU.,Manllold.d which tanks T Make Il known <br /> 8. UNDERGROUND Is the water over the lank7. <br /> WATER Depth to the Water table `'�"r�/ �`�'��y a Yes NO <br /> Tanks to be filledhr. Date Arraicped by <br /> 9. FILL-UP It Name Telephone <br /> ARRANGEMENTS Extra product to"top off'and run TSTT. Now and who to provide) Consider NO Load. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name - Ttlephone <br /> 10, CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information an any items above.Officials or others to be advised when testing Is In progress at completed.Visitors or observers present <br /> during lett etc.. - <br /> Tesla were made on the above tank systems In eccordence with test procedures prCe"rlbsd for f FO t} <br /> 12. TEST RESULTS as detailed on attached lest charts with results as follows: r Sir Ts rr <br /> Tank Identification Tight Leakage indicated Data Tested <br /> .cJ.c ,ES :833alll9 <br /> This Is to certlty that these tank systems were tested on the date(&)Shawn.Those Indicated an"Tig"Tight"meet the tilted.established by <br /> 13. CERTIFICATION <br /> the National irr Protection Asocation Pamphlet 929, 7 <br /> Date L.B.M.E.COIRPOFIATION <br /> 7.2 7 3814 Auburn Blvd.,Suite 82 sr: s�on.ture <br /> Se.ial No.or Th..mal Technicians -Sacramento,CA 95821 <br />