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1 , <br /> t Data Art for Tank System Tight#ss Test <br /> 2 petro Titer „ <br /> PLEASE PRINT � /` / / TANK TESTER J •�Q <br /> 1. OWNER Property �,���//�✓� <br /> Address /'= /r/ /R',oC.r•,•./,er/ul., v,jl i,leonon, <br /> 2. OPERATOR <br /> Name Addresf isn On°ne <br /> 3. REASON FOR <br /> TEST <br /> (EaDlain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name t.ne Company or urllanon <br /> pw <br /> Address te,onom <br /> 5. WHO IS PAYING <br /> FOR THIS TESTI Comoenr.Aamer or malyidmi Parson Amhond^g rine re,onom <br /> Billing Address City star. it. <br /> Arrnrrtn of: Olde,N0. OIneI In,IrUCIiOn, <br /> Identify by Direction Capacity Brand/Supplier Grade Approz.oAgeste.i/F.thergliks <br /> 6. TANKS) INVOLVEDlocation Cover Fills Ven,. Siphoneps <br /> 7. DASAALLATION C,,I»Lg L <br /> PAC 16 <br /> Tpe.r, CT <br /> No nn Imide dllv,wry. COnc rat,,Bpclt Too. $its.e..Ra m,e plop suction. Remol,, <br /> RNI 01 alallon,,Ie. E,IIn,etc, lu°,a.Ramble Fill, $il,,M,nil°Ided Which lane,I MaY,it Yn°wn <br /> B. UNDERGROUND <br /> WATEflDepIs the water over the tank? <br /> th to IM Water table � <br /> Tanks to be fille�hr. �'re <br /> 9. FILL-UP / pals Arranged <br /> No <br /> angad by } <br /> ARRANGEMENTS P rvame Tvidr,.n, <br /> UPS product to"lo off-and run TSTT. How and who to Provide 7 Consider NO Lead. <br /> Terminal or other contact <br /> for notida or inquiry_ TTO <br /> Como+nr Neme rueonone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any <br /> other contralto, <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional informatign on any items spoke.Officials or others o be advised when testing h In progress or Com Dieted.Vlsnors or opsove+s presem <br /> during test etc. <br /> Tanta wan mads on the above tank systems in accordance with test Procaduraa pre adnbed for "12110l <br /> } I}P <br /> 12. TEST RESULTS as detailed on Attached lost Chains with results as follows �IO thiel <br /> Tank Identification Tight fS _ 1esaka0s,�gae0/ <br /> ad <br /> "Tst.d Tested <br /> 13. CERTIFICATION This Is to cbtlfy that these tank systems were tested on this deals)shown,Those Indicated <br /> the National as"Tight"meet the criteria established by <br /> Fla protection Aaodlei pamphlet 379. <br /> pal. Lawrence Tank Testing a Q <br />/_�� /3� P.O. Box 407 <br /> $gnu Nil . n,c.nsSimilar, Downieville,Cafornia 95936 <br /> (916) 289-3109 <br />