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Data Chart for Tank System Tightness Test <br /> st <br /> petro Tite <br /> TANK PESTER <br /> I. OWNER <br /> Property <br /> Tank(s) <br /> Name .. Addresse.lr <br /> jelephon <br /> Name Address - <br /> 2. OPERATOR TerepAdne <br /> Name Address - <br /> 3. REASON FOR TEST Telephone <br /> /77 i i/Jl ar r l <br /> (Explain Fuhy) -_—��� � <br /> 4. WHO REQUESTED J _ <br /> TEST AND WHEN Name - Tlile ~� <br /> Gompany or Affili ion Date <br /> Address <br /> 5. WHO IS PAYING Telephone <br /> FOR THIS TEST? Company,Agency or Individual Person Authorizing Ti;te <br /> Telephone <br /> Billing Address Clty State <br /> Zip <br /> Attention of: Order No- Other Instructions <br /> 6. TANK(S) INVOLVED Identify by Direction Capaclty Grade Approx-Age Steel/Fiberglass <br /> b5L 1a <br /> � 5 `- -�f� 11 <br /> 7. INSTALLATION Location cover Fills <br /> Vents Siphon pumps <br /> r I? <br /> North insitle orAway, Concrete,Slack Top, Size,Ti1e111i make, }rap <br /> Rear of station,etc. earth,etc. tubes,Remote Fills Size,MarieoldaeSuction,Remote. <br /> UNDERGROUND <br /> Which Tanks? Make it known. <br /> 8. � <br /> WATER, Is the water over the tank? <br /> Depth to water table if known_ �'� <br /> ❑ Yes IM No <br /> 9. FILL-UP <br /> ARRANGEMENTS Tanks to be tilled Date Arranged by <br /> Hour �N. Telephone <br /> 10. TECHNICIANS <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 /> 12. TEST RESULTS Tests were made on the above tank,systems In accordance with test Procedures prescribed for petro rrtp <br /> as detail,on attached test charts with results as follows: wruc msi�e <br /> Tank Identification Fight Within Tolerance Out of Tolerance Date Tested <br /> 13. <br /> CERTIFICATION This is to certify that these tank systems were tested on the ciato(s)shown.Those indicated as"Tight"moot the erfterlro <br /> Protection Association Pamphlet 329. a established by the National Fa <br /> If rson certifying - <br /> Date <br /> �j —/2 711 T g C r for or Company, gn tura , <br /> Serial No.of Thermal Sensor Cortifcation Number `./ - - - <br /> .. Address* <br /> t . <br /> " t <br />