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r <br /> Data Chart for Tank System Tightness Test <br /> petro Tit? <br /> TANK TESTER <br /> 1. OWNER Property p y �- )kZ <br /> Addre � el <br /> Name �? aphonea <br /> Tanks) J is- elephone <br /> Name <br /> 2. OPERATOR sry,,xk� f989 <br /> Name Address Telephone <br /> 3 REASON FOR TEST !TH <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Witle ;ompapy or Affiliation Date <br /> Address Telephone <br /> 5 WHO IS PAYING <br /> FOR THIS TEST? Company,Agencyorindividual Person Authorizing Title Telephone <br /> Billing Address City State Zip <br /> Attention of: Order No. Other instructions <br /> 6. TANK(S) INVOLVED Identify by Direction Capacity Grade Approx.Age s(eallFibeglass <br /> 2— C),%C_ 7 5 <br /> 7. INSTALLATION anon Cover Fills Vents Siphons Pumps <br /> DATA /7'Fv_ a 75 AL-G_. <br /> f North ki driveway. Concrete.Black Top. Size.Tifefill make.Drop Sucher, Renate. <br /> Rear of etalion.ea. Earth.Hc. lubes.Remove Fills Size.Mdnitolded ii(asks' Make it known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to water table if known <br /> Yes No <br /> 9. FILL-UP <br /> Tankstobefilled Date Arranged by <br /> ARRANGEMENTS Name Telephone <br /> Hour <br /> 10. TECHNICIANS Cc-t 4- <br /> Ze <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials or others to ba 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 above tank systems in accordance with test procedures prescribed for }TO 11P <br /> as <br /> details on attached teal charts w s: ssTmT <br /> Tank Identification Tight Wimin Tolerance Out of Tolerance Data Tested <br /> -03 e3f- �p� l0 3- � 7 <br /> 13. CERTIFICATION This is to certify that these tank systems were tested on the debrief shown.Those indicated as"Tight"meat the criteria established by the National Fire <br /> Protection Association Pamphlet 329. <br /> 4 of person certifying <br /> Date l <br /> Tg Contract or Company. <br /> Sepal NO.OI Thermal Sensor Cedihalion Number Address / <br />