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N d <br /> Data 0&rt for Tank System Tighjpss Test <br /> petro Tde <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ C; tock e . <br /> Name Address Representative Telephone <br /> Tank(s) ❑ N - .,� t] c.a.. o S 7r <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED 7 c rr y c -F A s -t rZ«y r.7,e cQF <br /> TEST AND WHEN Name Tule Company or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING Cr <br /> FOR THIS TEST? Company,Agency or Individual Person Authorizing Title Telephone <br /> Billing Address Clty State Zip <br /> Attention of: order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED -5/k j Z I t-,- SO F C .2 o J r <br /> S w g 3 a c? _10— <br /> Location <br /> 0Location Cover His Vents Siphones Pumps <br /> 7, INSTALLATION Pe R r QF c""' "` rr `{ r' 2 <br /> DATA sfAf p-j <br /> North inside driveway, Concrete,Black Top, Size,Tltelill make,.Drop Suction,Remote, <br /> Rear of station,etc, Earth,etc. tubes,Remote Fills Size.Manifolded Which tanks 7 Make it known <br /> 8. UNDERGROUND Is the water over the tank l <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. Flow and who to provide 7 Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR, tz, oa c c .-.r Lrg&e d _S <br /> MECHANICS, AJe- u c <br /> any other contractor <br /> involved <br /> 11. OTHER cd r 5 T'1 1 :5112- - �c- Lc <br /> INFORMATION K' f•42"d <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 systems In accordance with test procedures prescribed for PPtro Ite <br /> 12, TEST RESULTS as detailed on attached test charts with results as follows: A"fA VT;SIFP <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> Z O ese Ye S oa — 21 —ir <br /> P uC 2l,) 1 -?Zf - 87 <br /> L;)Ai it r rit 4 e /t-J 0 b44 eD e- 7 <br /> This is to certify that these tank systems were tested on the date(s)shown.Those indicated as"Tight`meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asoclation Pamphlet 329. <br /> Date �/ Testing Contractor or Company. By: Signature <br /> Soria)No.of Thermal Technicians Address <br /> Sensor <br />