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e <br /> Data Chart for Tank System Tightness Test 87 <br /> petro TAP <br /> TANK TESTER <br /> 1. OWNER <br /> Property <br /> V <br /> Name /Q A t d s s Telephone <br /> Tank(s) (� 1?— <br /> Name Address Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3 REASON FOR TEST �I <br /> (Explain Fully) <br /> 4. WHO REDUESTED <br /> TEST AND WHEN <br /> Name Title ompany or Alf,1 Date <br /> .dress Telephone <br /> 5 WHO IS PAYING <br /> FOR THIS TEST? Company,Agency or n ividu son Authorizing/ Title Telephone <br /> Billing Address Lily Stale Zip <br /> Attention of: Order No. Other Instructions <br /> 6. TANKS) INVOLVED Identify by Direction capacity Grade Approx.Age SteelfFiberglass <br /> 2 5 <br /> 7. INSTALLATION Location Lover Fills Vents Siphons Pumps <br /> DATA <br /> Norah inside driveway. Concrete.Black Top, Size.Tilelill make.Drop Suction.Rempt¢. <br /> Rear of slanon.etc. Earth,etc. tubes.Remote Fills Size.Mandolded Which tanks? Maxed known. <br /> 8. UNDERGROUND ';> Is the water over the tank? <br /> WATER Depth to water table if known ❑ Yes No <br /> 9. FILL-UP Tankstobefilied r— Late Arranged by <br /> ARRANGEMENTS Name Telephone <br /> Hour <br /> 10. TECHNICIANSAllis-it , 14 <br /> 11. OTHER (� <br /> INFORMATION <br /> OR REMARKS )3 <br /> A.!TH <br /> Additional information on any items above.Officials or others to De advised when testing is in progress or completed-Visitors or observers present <br /> during test,etc. <br /> 12. TEST RESULTS Tests were made on the Top"tank systems In accordance with test procedures prescribed for Wr0711P <br /> as details on attached test chert.with results as follows: TA.1'as <br /> Tank Identification Tight Within Tolerance Out of Tolerance Date Tested <br /> ic�` 7 <br /> 13. CERTIFICATION This Is to certify that these tank systems were tested on the dale(s)shown.Those Indicated as"Tight"meet the criteria established by the National Fir. <br /> Protection Association Pamphlet 329. <br /> 7 1Nd of person certifying <br /> s0 0 ! <br /> Date —_� <br /> Te I ntrado r ompany ur /J <br /> II K <br /> Serial No.of Thermal Sensor Certifcation Number Address <br />