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Data Chart for Tank System Tightness Test <br />ro 'te <br />TANK TESTER <br />1. OWNER �! S �L'!.4%� K- Jc-) e2. d <br />Property <br />Name / g // Address^ <br />�Tank(s)?—L�) <br />Name Address <br />2. OPERATOR <br />Name <br />3. REASON FOR TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Telephone <br />Name Tale G`n. M% 1"RMY,1 A HEALTH r t Date <br />5. WHO IS PAYING <br />North inside driveway, Concrete. Black Top, <br />Rear of station. etc. Earth, etc. <br />Size. Tifefill make. Drop <br />tubes. Remote Fills Size, Manilolded <br />FOR THIS TEST? <br />Company, Agency or Individual <br />Person Authorizing Title <br />Telephone <br />- <br />Billing Address <br />City State <br />Zip <br />Tanks to be filled �5 - � � Date <br />Hour <br />Attention ol: <br />Order No. Other Instructions <br />10. <br />6. TANK(S) INVOLVED <br />Identify by Direction <br />Capacity Grade Approx. Age <br />Steel/Fiberglass <br />OTHER <br />INFORMATION <br />____._ __.._____._______- _ _-----.__ . <br />/` <br />----�� <br />OR REMARKS <br />7. INSTALLATION Location Cover Fills Vents Siphons Pumps <br />DATA ILLI% 'L cP� L� f G/ ., �. /0 o ie _ �v' 'e - <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 POWLIP <br />as details on attached test charts with results as follows: trva sr v — <br />Tank Identification Tight Within Tolerance Out of Tolerance Date Tested <br />16' AeP.L1 <br />13. CERTIFICATION This into 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 />ame t person certifying <br />Date - <br />Serial No. of Thermal Sensor Certification Number <br />North inside driveway, Concrete. Black Top, <br />Rear of station. etc. Earth, etc. <br />Size. Tifefill make. Drop <br />tubes. Remote Fills Size, Manilolded <br />Suction, Remote, <br />Which tanks? Make if known. <br />8. <br />UNDERGROUND <br />WATER <br />^, <br />Depth to water table if known <br />Is the water over the tank? <br />❑ yes No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled �5 - � � Date <br />Hour <br />Arranged by <br />Name <br />Telephone <br />10. <br />TECHNICIANS <br />GQ I e�"A <br />© ' <br />11. <br />OTHER <br />INFORMATION <br />____._ __.._____._______- _ _-----.__ . <br />___..._-------- _.--------- _._..... __ <br />----�� <br />OR REMARKS <br />- ----_v <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 POWLIP <br />as details on attached test charts with results as follows: trva sr v — <br />Tank Identification Tight Within Tolerance Out of Tolerance Date Tested <br />16' AeP.L1 <br />13. CERTIFICATION This into 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 />ame t person certifying <br />Date - <br />Serial No. of Thermal Sensor Certification Number <br />