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to <br /> Tite► <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ Telephone <br /> ❑ Name 7rF Ad ma Rwmwutira <br /> Tmk(a) <br /> Name Addrm wnaentative T+IeMona <br /> 2. OPERATOR Name Aearos. Telephone <br /> 3. REASON FOR < <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED � k < <br /> TEST AND WHEN N"n' Tnle Comwnr or Aniltalun Data <br /> 'r cec— L r / no <br /> Addrase Telephone <br /> 5. WHO IS PAYINGc f o^d <br /> FOR THIS TEST? Company. ,enc1 of lnaiviau.I Person Authoming rill. Telephone <br /> Bunn,Address City sun. zip <br /> Attention of Omer No. Other lnatmzo.hs <br /> Identify by Direction Capacity Brand/Supplier Gratle Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED S o r S< C <' <br /> Location i.�/t Cover Fills 2 r r Vent y r Siphons Pumps <br /> 7. INSTALLATION oti 4 o c a t e 5 <n <br /> DATA of Ho-Sc <br /> North Inside driveway. Concrete.Black Top. Size,Therflll make.Drop Suction.Rempu. <br /> Res,of eutlon.etc. Earth.etc. too..,Remota Fills Size.Mwilolded Which tanks? Mak•if known <br /> 6. UNDERGROUND Is the water over the lank? <br /> WATER Depth to the Water table J ❑ Yes No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Nem. Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Telepnone <br /> 10. CONTRACTOR, SYoc oti Se/ , cc r i+eN e - r l <br /> MECHANICS, r L: t o ti r It, r.. d, <br /> any other contractor n/ / <br /> involved <br /> F E7/44 <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials or others to be advised when lasting is in progress or completed.Visitors or observers present <br /> during test etc. <br /> Tests were me&on the above tank systems in accordance with test proc•dums prescribed for Pero ylte <br /> 12. TEST RESULTS as detalled on afteched test charts with results as follows: i.— <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> S u 'e e 5 4- - /1' - 91 <br /> This In to certify that thew tank systems ware tested on the dete(s)shown.Those Indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asoclatlon Pamphlet 329. }�y ®®//�J <br /> .•3 - /a ' �7 Te�R� CA �r S C 'Y y of c7ocic b !lG'<<iil�w G cf <br /> Dna �:.hn,comr.oml or comp• or. s,n.mre <br /> Sww1_hamr.ss S nw.a Thwmel uonmptans A .. <br /> So. <br />