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Dathart for Tank system Ti�)ness Test <br /> p fro T te <br /> PLEASE PAINT TANK TESTER <br /> 1. OWNER Property L✓ 7'1( C- LC. [ rr 0-4 t,- 71/,�.-'f T t4 <br /> Name Address. Retiresentatwn Telephone <br /> Tank(s) <br /> Name Address - Representative Te1eOflOne •I <br /> 2. OPERATOR <br /> Name Address ieieonona <br /> 3. REASON FOR <br /> TEST t- •, L . , 77 <br /> {Explain FLA10 <br /> i <br /> i <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title CompanvofAffiliation Date <br /> Addles! Tolepri"o <br /> 5. WHO IS PAYING s <br /> FOR THIS TEST? pane,Aq cyy of Individual L Person Autnotiaina Tide Tesebnone <br /> Billing A "M CITY State Zip <br /> Attention of; Order No. Other instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(Si) INVOLVED 5ti Xbt Q ' L(= -) 3'7', <br /> 4 <br /> O 2. <br /> G P1G �" <br /> I !`( SI`rrr�ir <br /> Location Cover Fill* Vents Siphons Pumps <br /> 7. INSTALLATION <br /> DATA C�ticiuzCt� 4( f! Z it 1211(J TlLc K� r <br /> North inside driveway. Concrete.Black Top, Site.Titeffil make,Drop - Suction.Remote. <br /> Rear of station,etc. Earth.etc. tubes.Remote Fills Size.Marufowod Which tanks? Make if known <br /> S. UNDERGROUND Is the water over the tank? a <br /> WATER Depth to the Water table Yes u No <br /> Tanks lobe filled hr, Date Arranged by � <br /> 9. FILL-UP Name Teleonone <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 <br /> Comasny Name 7yieohdne <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other conlractor <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 <br /> during test etc. in W09011133 or camplelpd.Visitors or observers present <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for Piro Tt}! <br /> 12. TEST RESULTS as detailed on attaches lost Charts with results as follows: " '' — <br /> Tank Identification t Leakage Indicated Date Tested <br /> +_ } — _ 7 <br /> �� I -3 2 <br /> A 1 a <br /> I <br /> This is to Certify that these tank systems were tented on the dates)shown.Those indicates as"Tight"msm the criteria established by ' <br /> 13. CERTIFICATION the National Firs Protection Aaociation Pamphlet 324. <br /> z ~ `-f _4.L o je V K[3 Q Lawrence Tank Testing -7� � T <br /> Date <br /> !Z lt L 7 - Ci 1 Y P.O. BOX 407" Signature <br /> Serial No.of Thermal - Technicians Downieville,California 95936 (91+5) 289-3109 <br /> Sense <br />