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Data art for Tank System Tigi less Test <br /> petro Title 1 v <br /> PLEASE PRINT TANK TESTER 14N 41988 <br /> 1. OWNER Property ❑ C Ep1Y1R61MFN)TAL HEALTH <br /> Nsma Addias Repre,enuU s <br /> Tinkle) ❑ �l W N DaJ PERI <br /> Nsma AMink -Representative Telephone <br /> 2. OPERATOR Name Address Telepnone <br /> 3. REASON FOR `^ s o r -/'0..J <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED k P` -c 9 <br /> TEST AND WHEN Nama S. CoC Title t ComwnY or Rilutlon 2_ / 00 <br /> Addreu Telephone <br /> 5. WHO IS PAYING o aj <br /> FOR THIS TESTI Company. gency or l ndivicurl Person Authorities La Taapnone <br /> aging Address city Sul. zip <br /> Attention oI: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Appmx.Aga Steel/Fiberglass <br /> 6. TANK(S) INVOLVED w O 'e St- L e <br /> Location Cover Fills Vents Siphons Pumps <br /> 7. INSTALLATION 4r. a to('✓cr ro^ rrt ie � " 2 'r 5O <br /> DATA 0.17F'r< L c "1,o� <br /> North Inside driveway, Concrete,Bleck Top. Size,Titafill make,Drop Suction,Romero, <br /> Roar of station,otc. Earth.etc. tubee.Remote Fill, Size.Manifolded Which ranks? Make if known <br /> 8. UNDERGROUNDq p ,r Is the water over the tank? <br /> WATER Depth to the Water table!t < < Or / ❑ yes ® No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name T.I.phon. <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. Now and who to provide 7 Consider NO Lead. <br /> Ntry rp <br /> Terminal or other contact <br /> for notice or inuiry e A ,In S ! Csn <br /> Company Nem. Telepnone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <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 /> Tests were made on the above tank systema in accordance with test procedures prescribed for Ira TI}p <br /> 12. TEST RESULTS as detailed on attached test charts with results a9 follows: M IE <br /> Tank Identification Tight Leakage Indicated Date Tasted <br /> W <br /> This is to certity that these tank systems were tested on the date(s)shown.Those Indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> 9- /4- P7 TcRky rA-1e5 C.'� �f _ i'e --o+1 /firt.J e. < <br /> Dee To ling Contractor or Company. By: signature <br /> 119 .3— /n{ ti/ tow <.'y. <br /> Bede No.of Thermal Technicians Address <br /> Senate <br />