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Data Chart for Tank System Tightness Test <br /> petro Tite <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ 13 _ cn <br /> O <br /> Tank(s) ❑ Nam. Aaeresa q <br /> w.a•mnl.e renonona <br /> Name Aeereas R.ouamlaave <br /> i•I•onen. <br /> 2. OPERATOR <br /> "a'"• Aaerosf <br /> r.Honene <br /> 3. REASON FOR T <br /> TEST <br /> IEaplain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN "'m• rill. <br /> Company Or Allllptlon par• <br /> AEerfs <br /> t UsonOne <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Cernea^y Ae•ncy of Individual Penen A.Moddng <br /> Tllb <br /> Sitting AAddressTtl•ohgne <br /> CIW star. ZIP <br /> Albndon Of: <br /> Old.,No. Olnel lnanuCtOnF <br /> Identify by Direction Capacity Brand/Supplier Grade <br /> 6. TANK(S) INVOLVED Approy.Age Steel/Fiberglass <br /> 96(2009 <br /> c f 3 00C t I -LzD e- <br /> F O II <br /> L 14 <br /> Location Cover Fills <br /> Vents Siphones Pumps <br /> 1: INSTALLATION FRONT O'E .Cpm, + <br /> DATA ,ST-DRE- BLK.TDP If /L Z /( <br /> w/9YN <br /> North Insle.erlvewq. Cenuele.Black iog. Siu,eirella make.Oreo � <br /> P•llel sbllOn,ac. Earth.alc. mbu.Ramole Fill. Siad,Mealloleed WMcn...W SOcuont R.mplej <br /> 8. UNDERGROUND uct own <br /> WATERIs the wale'ovef the tank? <br /> Depth to the Wafer table _ ❑ <br /> A Yes 0 No <br /> Tanks to be filled 0Y0 0� hr._�'-Z.C(— <br /> 9. FILL-UP y Dale Arranged by <br /> ARRANGEMENTS Extra product to'.top off"and run TSTT. How and who to Provide? consider N Harr. T•Ieonone <br /> 0 Lead. <br /> Terminal or other contact <br /> for notice or Inquiry <br /> Cemoany <br /> 10. CONTRACTOR, Name Tele Ohon• <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information onany items above.011iciah or ethers to ba edvisetl when ustinp is in progress or completed.Visitors or observer <br /> during test are. <br /> presem <br /> Testa were made on the above lank systems In accordance with lest procedures prescribed for <br /> 12. TEST RESULTS as <br /> detailed on attached test charts with results as follows: PFn•trogT11P , <br /> Tank Identification Tight <br /> Leakage Indicated D <br /> vc.�r it ate Tested <br /> _- <br /> cusiv- <br /> This Is 10 cerlly that Ihaee lank eye,.,.iatlonPa <br /> 13. CERTIFICATION the National Fire Protection Asoelallen were tested on the date(s)shown.Those Indlcaled as"Tight"meet the crilerle established by <br /> t <br /> -0o_. Lawrence Tank Tesfin <br /> g <br /> Sepal No.of Tnermal P.O. Box 407 �— <br /> Slgnalu��� <br /> Sanfbr `•°"^1pj•na Downieville,California 95936 <br /> (916) 289-3109 <br />