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e <br />Mart <br />Data for <br />Tank System <br />Tightness Test <br />trO <br />T1tP <br />TANK TESTER <br />1 OWNER Property <br />Tank(s) <br />Name �" <br />�.J �� <br />A; <br />t�. <br />•, <br />Telephone <br />Name <br />Address Or <br />I ENO I <br />Telephone <br />2. OPERATOR <br />.�.g �'�' g(��+� <br />5� , 40ad <br />Name <br />Address <br />b4' <br />Telephone <br />3. REASON FOR TEST <br />e /: j So l e_CA w,v <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Name <br />Title <br />Comoanvor Affiliation <br />Data <br />5. WHO IS PAYING <br />FOR THIS TEST? <br />Attention of: Order No. Other Instructions <br />6. TANK(5) INVOLVED Identify byDirection <br />e 1 Capacity Grade Approx. Age Steel/Fiberglass <br />4 e �( ?� c,+� �,% #".z0.5 ( �?' 3Tom../ <br />7. INSTALLATION Location Cover Fills Vents Siphons Pumps <br />DATA S. S r ,O�n a,f b% 29 -r q `r & f 1,yfP AO. <br />North inside driveway. Concrete. Black Top, Size, Tilelill make. Drop Suction. Remote. <br />Rear of station. etc. Earth, etc. tubes, Remote Fills Size, Manitolded Which tanks? Make if known. <br />8. UNDERGROUND Is the water over the tank? <br />WATER Depth to water table it known <br />❑ Yea � No <br />9. FILL -UP <br />ARRANGEMENTS Tanks to be filled Date Arranged by <br />{`�/L^► Name.///� q T Telephone <br />Hour __ /) a �� <br />10. TECHNICIANS !� a, - f <br />11. OTHER R� <br />INFORMATION �__� <br />OR REMARKS -�rt _ <br />!111 - <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 />12. TEST RESULTS Tests were made on the above tank systems in accordance with test procedures prescribed for IroT' <br />as details on attached test charts with results as follows ra. esus <br />Tank Identification Tight Within Tolerance Out of Tolerance Date Tested <br />/q, CP 4)0 A7&ai0XV i- (7-ii� <br />13. CERTIFICATION This is to certify that these tank systems were tested on the dates) shown. Those Indicated as "Tight' meet the criteria established by the National Fire <br />Protection Association Pamphlet 329. <br />IV -7 Name of person certifying <br />Date j $ - <br />sting ontractor or ompany y: S' natu <br />r t <br />al Ne. OfTharmal S®nsor Gertifoad9n Number Address % <br />