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Data C' art for Tank System Tigh,,,Oless Test <br /> petro Tde <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ o /c O A..) <br /> R <br /> Name Admm •pwssntatiy Telephone' <br /> Tanks) ❑ N CO %M N41 A <br /> 02 <br /> Name Address R•preMnYYve .assal n• <br /> 2. OPERATOR Name ,woes, Talaohow <br /> 3. REASON FOR 0aC A " aJ <br /> TEST <br /> (Explain Fully) <br /> -47 <br /> 4. WHO REQUESTED �'�� 8 a. <br /> a. <br /> TEST AND WHEN "+me S. : „� Core — if_ o Dwewlrvo(AA.gon _D/ 00 <br /> ANrpt Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TESTI Comp+nY.Agan<v or Indivwu+l P•un Authorizing Tilde Telephone <br /> Billing Address City stat. zip <br /> Austrian at: Order No. Other Inmucdons <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED w Q S C) Sc 1. 3 O S tee <br /> Location Cover Fills Vents Siphons Pumps <br /> 7. INSTALLATION -/W (otre /' Corr C�e ti �7' .2 �' Su Cfi o ^j <br /> DATA OIC <br /> Norm Inside driveway. Conorele.Black Top, Size.Tilafill make.Drop Suclwn,Remote. <br /> Rear of.talion,eta Eenh,e¢. tubes.Remote Fills Sure,Mmlloldea which tanks 7 Make it known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table Q e-Lo w /O GT ❑ year ® No <br /> Tank,to be filled N. Date Arranged by <br /> 9. FILL-UP Name 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, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER t & Oft, * o I p <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials or others to be advised when tasting is in progress or completed.Visitors or observers present <br /> during test etc. <br /> Tests were made on the above lank systems in accordance with test procedures prescribed fluf0�} <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Data Tested <br /> w <br /> This Is to certify that these tank systems were tested on the details)shown.Those Indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asoclation Pamphlet 329. <br /> to Ci ,y ofto cki - <br /> Date <br /> l sipnp onvactor or Comw yl By. Ivte <br /> 'Serial N�o1.of Thermal 6J S. L: At Ce Cr Sy. V r an 7 A,I <br /> Aad. <br /> Sensor <br />