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Data G,,.rt for Tank System Tigh►•_,ss Test <br /> _ .. _ _ _. .. _ -petro TitP <br /> TANK TESTER <br /> PLEASE PRINT <br /> 1. OWNER Property ❑ <br /> ❑ Name Address Representative Telephone <br /> Tank(s) <br /> _ Name Address R.tiresenlatire Telephone <br /> 2. OPERATOR .m. Ada. `— Telephone <br /> 3. REASON FOR <br /> TEST ,t <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company or Affiliation Data <br /> Address Telephone <br />• 5. WHO IS PAYING Title Telephone <br /> FOR THIS TEST? Company,Agency or Individual Person Authorizing <br /> Billing Address city Stale Zip <br /> Attention ol_• Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Ste /Fiberglass <br /> 'TANK(S) INVOLVED &0 <br /> r Location Cover Fills Vents Siphones Puu ss <br /> 7. INSTALLATION <br /> DATA <br /> I North inside driveway, Concrete,Black Top, Size,Titelill make,Drop Suction.Remote, <br /> Rear of station,etc. Earth,etc. tubes.Remote Fills Size.Manilolded Which tanks? Make If known <br /> $. UNDERGROUND _ / // Is the water over the tankT <br /> WATER Depth to the Water table / ❑ Yes No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP � Name 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 Telephone <br /> Company Name <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 lank systems in accordance with lest procedures prescribed for PPtrO Ut—e <br /> 12. TEST RESULTS <br /> as detailed on attached test charts with results as follows: " r's`'` <br /> Tank I entification Tight Leakage Indicated - Date Tested <br /> �aJ • 94 <br /> /—,z <br /> This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight"meet the criteria stabiished by <br /> 13. CERTIFICATION the National Fire protection Asociation Pamphlet 329. , <br /> Date Testing eonvatlor or ompany. Sr t re <br /> Serial Nd of Thermal TechmCJan, Address <br /> Sensor <br />