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Data G_ _�t for Tank System Tighk is Test <br /> _ petro Tite <br /> PLEASE PRINT �y TANK TESTER <br /> 1. OWNER Property El <br /> N me <br /> Add Repress ntativ Telephone <br /> Jl� _ <br /> Tank(s) I /./S C`l_ <br /> ..- — Name �(/ Add Us Ra Dresa nl nive Telephone <br /> 2. OPERATOR Telephone <br /> Name Address <br /> 3. REASON FOR - r' <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN N.me Title Company Or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING Title Telephone <br /> FOR THIS TEST? Company.Agency or Individual Person Authorinnp <br /> Billing Address <br /> city state zip <br /> Attention of: Order No. Other instructions <br /> Identify by irection Capacity Brand/Supplier Grade Ap rox.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED <br /> Locatio `— Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION <br /> DATA <br /> IV n rO <br /> leLl �/cc's <br /> North inside driveway. Concrete,Black Top. Size,Tilefill make,Drop Suction,Remote, <br /> Rear of station,etc. Earth,etc. tubes,Remote Fills Size.Manilolded Which tanks? Make if known <br /> Is the water over the tank) <br /> 8. UNDERGROUND / <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 /> Extra product to"top off"and run TSTT. How and who to provide? Consider NO Lead. <br /> ARRANGEMENTS <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 tank systems in accordance with test procedures prescribed for Pf T11P <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> •.,lisuc <br /> Tank Identification Tight Leakage Indicated Dale Tested <br /> � <br /> h� 1 0 '3 ILhIGic6 y �c — P�1--- �f�"--- -This is to certify that these tank systems were tested on the date(s)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. , 1 <br /> I u ►Z��'S� �I /� <br /> Tesn Conuactoi of Company_ By. Sena <br /> Serial No of Thermal Tec h�ic�a ns Address <br /> Sensor <br />