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Data C art for Tank System Tigh ess Test <br /> petro Tate <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ G / 8 <br /> Tanks Name Address R.pesenrative Telephone <br /> '/5 E. NP STo enJ <br /> Name Address <br /> flaprexnra ve Telephone <br /> 2. OPERATOR <br /> Name Address <br /> Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN N.me Title Company of Affiliation Data <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TESTI Company.Apancy or Individual Person Authorizing Title Telephone <br /> Billing Addsass City sure zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steal/Fiberglass <br /> 6. TANK(S) INVOLVED a. O /CL/Q /A5t <br /> Uircir L g <br /> oRr AR 5S <br /> Location Cover Fills Vents Siphoms Pumps <br /> 7. INSTALLATION Al.ourn /w S cfra <br /> DATA rgs.+T 0 A <br /> 5-rA1-,eeJ Ce A)CICrC <br /> North Inside driveway, Concrete.Black Top, Size,Titelill make.Drop P� suction,Remota. <br /> Rae,of sIetlon,etc. Ee,th,etc. tubae.Remote Fills Sia.,M.nlloldad Which ranks s Make it known <br /> B. UNDERGROUND /] O Is the water over the fank <br /> h7 <br /> WATER Depth to the water tableUJA CR /e'/OW 'raAdr PJ -frN Yes N1No <br /> Tanks to be filled T-hr. Date Arranged by <br /> 9. FILL-UP N.ma Telephone <br /> ARRANGEMENTS Extra product to"top off-and run TSTT. How 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, Clcu,iallrh 9q" A <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER N14W rA1Q6I2VLJACIf did6lCh e - /2 <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 systems in accordance with test procedures prescribed for PP}To TIIP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: _Ir— <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> u H �j- IlI- <br /> P E # o - <br /> I�Io2TN + 0/0 <br /> This Is to certity that these tank systems were tested on the d own.Those indica as' ght"m t the criteria established by <br /> 13. CERTIFICATION the Nat naYFlProtection Asociation Pamphlet 329. <br /> Data T ftl ontneto,ornK By s ams <br /> Sexual No.of Thermal Tecnnlnans q orae <br /> Senear <br />