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Data Chart for Tat c T tP Tight D <br /> 0 <br /> t . TANK TESTER 1. OWNSIrp' <br /> Property ��Y S6n(i6aQAnlD �tdl 9QZ— DZbO <br /> Nam,' gddreas Telephone <br /> Tanks) �' 707 �. _C2V IQQ ENVIRONINM--aE-�NTAL HEALTkh" <br /> Name Address C'('y"".aERVIL�E.S--- Telephone <br /> 2. OPERATOR CSAME As -44!x ) <br /> Name Address Telephone <br /> 3. REASON FOR TEST AaVA/bA E[JwQErr�nlT <br /> (Explain Fully) <br /> 4. WHO REQUESTED �j— �TX� �EaJBaQAw/b' <br /> TEST AND WHEN Name Tree Company or Affiliation oats <br /> Address Telephone <br /> 5. WHO IS PAYING H d T9Aak(S 1S BP,ot/d UwaVE� <br /> FOR THIS TEST? Company,Agency or Individual Person AuthorlNng Tree Telephone <br /> Billing Address City State ZIP <br /> Attention of: Order No. Other Instructions <br /> 6. TANK(S) INVOLVED Identity by Direction Capacity Grade Approx.Age SteelIFiberglass <br /> 7. INSTALLATION Location ''nn Cover Fills Vents Siphons Pumps <br /> ML DATA N 4 e4j,, e,,Wea?ETE 4# Subowesii <br /> North inside driveway, Controls.Black Tap, Size.Tifetill make.Drop Suction,Remote, <br /> - Rear of station,etc. Earth.etc. tunes.Rankle Fills Slee,Mandolded Which tanks? Make it known. <br /> 8. UNDERGROUND q Is the water ova the tan ? <br /> WATER Depth to water table If known ( ❑ vas CJ No <br /> 9. FILL-UP <br /> ARRANGEMENTS Tanks to been (_ 17_� <br /> ed Date Arranged byJiwt lie <br /> Name Telephone <br /> �dap Hour <br /> 10. TECHNICIANS �� —� �� <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional Informatlon on any Items above.Officials or others to be advised when testing Is In progress or completed.Visitors or observers present <br /> during test,etc. - - <br /> 12. TEST RESULTS Teats wan made en the above tank systems In accordance with test procedures prescribed for T e <br /> as details on attached test charts with results as follows: <br /> Tank Identification Tight Within Tolerance Out of Tolerance Dale Tested <br /> eg <br /> wesr�tlh _ c-4.5 <br /> 13. CERTIFICATION This Is to certify that those tank syanma wan tasted on the dot*(,)shown.Those Indicated as"Tight"meet the cdteds established by the National Fire <br /> Protection Association Pamphlet 379. <br /> Nameofpeerrs'onn ccorttiffyinng <br /> �y.. <br /> r tg <br /> Date l F O t ><a .LhfJ . 1 KFWG7al� —^Ifork, 0 j ` C — <br /> s <br /> 'Testi n ntractor y B $i n tur <br /> rk <br /> ` G� I�o �F/d&3►d5 351 �d. ee�.a <br /> � � Serial No.o Shermel Sensor Cetllfctlion NumDH Address <br />