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uata Gn Ter IanK bystem i ignin Is <br />Iest <br />petro Tice <br />PLEASE PRINT TANK TESTER <br />1. <br />OWNER Property [] <br />Tank(s) ❑ <br />Name A,4 epresentative <br />N iD <br />Telephone <br />Mama Addrees Raprasentailve <br />Telephone <br />1. <br />OPERATOR <br />- <br />Na me Address <br />Telephone <br />3. <br />REASON FOR <br />ov %,p 4reS <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />Te -Sr <br />f f <br />TEST AND WHEN <br />Name Tine Company or Affd orlon <br />N <br />Data <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />C In c k Y a ^.J <br />FOR THIS TEST? <br />Company, A ency or Individual Person Authorizing Title <br />Telephone <br />Billing AdQress City State <br />Zip <br />Attention of: Order No. Other instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />v <br />Capacity <br />S <br />Brand/Supplier <br />Grade <br />e S e <br />Approx. Age <br />Steel/Fiberglass <br />7. <br />INSTALLATION <br />DATA <br />'Location p tj <br />Ad - <br />r <br />North Insil rlvevvy, <br />near of station, ata <br />I Cover <br />Concrete, Bleck Top. <br />Earth, etc. <br />Fills <br />Size. TiteBll make. Drop <br />tubas, Remote Fills <br />Vents <br />Size, Manifolded <br />Siptwnes <br />which tanks i <br />Pumps <br />Suction, Remote, <br />Make It known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table E] Yes Na <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name <br />Extra product to "top off" and run TETT. How and who to provide? Consider NO Lead. <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />10. <br />CONTRACTOR, <br />` C k *c'^� <br />MECHANICS, <br />any other contractorC <br />771! P2 cA S <br />involved <br />11. <br />OTHER <br />INFORMATION <br />e e A ol At' <br />OR REMARKS <br />Additional information on any items above. Officials or others to be advised when testing is in progress or comptetad. Visitors or observers present <br />during teat etc. <br />12. <br />TEST RESULTS <br />Tests were made on the strove tank systems in accordance with test procedures prescribed for �! <br />TI <br />as detailed on attached test chane with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />o i t 5 <br />This Is to cartery that these tank systems were tested on the datejs) shown. Those Indicated as "Tight" meet the criteria established by <br />13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br />_1-? - /6 - 8i Ire, e -A 41-s c r, Y 1' r� S f t��, r d <br />Det. p <br />THtinq Contractor or Company. y :Signature <br />f S S Z/'lj/�� S- s. <br />Serial No. Of Thermal Technicians Address <br />sorom <br />