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' Data Chalk Tank System Tightnes est <br />TANK TESTER <br />1. OWNER Property <br />Tank(s) <br />2. OPERATOR <br />3. REASON FOR TEST <br />(Explain Fully) <br />// �'-��.)Q it- - ds>& ­')Ne -Pe– C Za 9 <br />Name ----""" <br />Name Address <br />3:1__q911 <br />4. WHO REQUESTED ,D CL a S a L -v -o Lr-,- <br />Title Comdany or Affiliation Date <br />TEST, AND WHEN Name `~ <br />Addjess LL, g@@ Telephone <br />LTfj <br />5. WHO IS PAYING ft cs U �'" <br />FOR THIS TEST? Company, Agency or individual <br />Person Authorising FOR <br />Billing Address <br />City State Zip <br />Attention of: Order No. Other Instructions <br />Capacity Grade Approx. Age SteeilFiberglass <br />6. TANK(S) INVOLVED Identify by Direction <br />/ _ c- Jo wc• s ".1 A ,:� a je � Ue es, S f�.�� <br />7. INSTALLATION Location _ Cover <br />DATA .3.0oA cde. <br />North inside driveway, Concrete, Black Top. <br />Rear of station, etc. Earth. etc. <br />8. UNDERGROUND `r <br />WATER Depth to water table if known <br />9. FILL -UP <br />ARRANGEMENTS <br />10. TECHNICIANS <br />11. OTHER <br />INFORMATION <br />OR REMARKS <br />Tanks to be filled _ 9 -Cate <br />Hour <br />Fills <br />i. <br />Size. Titefill make, Drop <br />tubes. Remote Fills <br />Arranged by ` <br />4A> <br />Vents <br />Siphons Pumps <br />Suction, Remote. <br />Size. Mamlolded Which tanks? Make it known. <br />Is the water over the tank? <br />❑ Yes No <br />Name Telephone <br />Additional information on any items above. Officials or others to be advised when testing is in progress or completed. Visitorsor 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 petro . ite_ <br />as details on attached test charts with results as follows: <br />Tank identification Tight Within Tolerance Out of Tolerance Date Tested <br />13. CERTIFICATION This is to certify that these tank systems were tested on the date(s) shown. Those indicated as "Tight" meet the criteria established by the National Fire <br />Protection Association Pamphlet 329. <br />... 4 -7 Name of erson certifying <br />Craw !� <br />DIS <br />Serial No. of Thermal. Sensor <br />Certifcation Number ��" <br />