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Data (*art for Tank System Tigh9ess Test <br /> petro Tote <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property E] 710 <br /> 7 5 /. <br /> Name Address <br /> Tank(s) � Representative TelepM1ona <br /> Name Addled. Representative TelepM1dne <br /> 2. OPERATOR <br /> Name Address Terepnone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN NBTB Tine Company pr Adninidn oats <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company,Agency or Individual Person Authorizing Title Telephone <br /> Billing Address City Sute Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED Sc C S74e <br /> H P <br /> Location CoverFills /IZ/) Vents �/ Siphones Pumps <br /> 7. INSTALLATION Al/ �� �/a�wT�/ Coe rc a 5vbv Pa•ar �/G <br /> DATA <br /> vdy� -Ft,Lie 5 <br /> concede, J/ <br /> North inside d e,stet'. Concrete,Black Top. Size.es,simple <br /> make,Drop Suction.Remove, <br /> nown <br /> Reu of sutlers,etc 6rtM1,etc, tubas,flemou Fills Size.Manllolded Which tanks? Make 11 known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table 11 <br /> ❑ Yes No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name TalaDM1one <br /> ARRANGEMENTS Extra product to"top oM'and run TSTT. How and who to provide? 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 <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 systems in accordance with test procedures prescribed forPPtro Tite <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: T— <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> �e a <br /> 71. Op 5 61P -�8- & <br /> - 9 -97 <br /> le c CO3 — <br /> This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight"meet the criteria established by <br /> 11.3. CERTIFICATION the National Fire Protection Asociaeon Pamphlet 329. / `�� / 1 <br /> M., .?rY '— b _/ 1 t rand. • r 1 /l i; /" <br /> Teftrnp Contac or or Co ny. BY: Sgneture <br /> IEa� l �' l ��k Sr �t.�a�? r <br /> Senal No.of Thermal Techd s Address <br /> Sensor <br />