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Data Q&rt for Tank System Tigh*ss Test <br /> petro Trte <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ c 'y o S o c k fi e N <br /> El <br /> ma Address Representative Telephone <br /> Tank(s) o $ V n.+ <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR rNsJ4 c f- P <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED � F' s L« - - <br /> TEST AND WHEN Name Tine Company or Affiliation Date <br /> / A.a C.C� <br /> Andreas Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company,Agency or Individual Parson Authorizing T , Telephone <br /> Billing Address City Soto Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grad. Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED �`j D;c SPL SS O m e a c 3 d S yr <br /> Lo anon Cover Fills ?/ Vents Siphones Pumps <br /> 7. INSTALLATION G rA S S 2 eN <br /> DATA _ <br /> North Inside driveway, Concrete,Black Top, Sin,Merrill make,Drop Suction,Remote, <br /> Rear of station,em. Earth,atc. tubes,Remote Fills Size,Manilolded Which tanks? Make it known <br /> B. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table — ❑ Yes ❑ No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off'and run TSTT. Haw and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company 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 etc. <br /> Tests were made on the above tank systema in accordance with test procedures prescribed for petroTItP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: � <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> Ya Di ars eC Ile S — a Ol /— <br /> This Is to certify that these tank systems were tested on the cartels)shown.Those indicated as"Tight"meat the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> TerPyl r'Aley C: I / o: SfecKfasv /�e� r` c �✓ e� <br /> Dale Testi ng Conu¢torm Company. By: &pnaWro <br /> Sonal No.of Thermal Technicians Address <br /> Sensor <br />