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uata tonan i0( iam Jystem i igntness lest <br /> petro TitP <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ A-.co P.O. Box 5811 San Mateo, Ca 6. 94402 Ron M.itu 1-800-421 -7457 <br /> ❑ Name Addteu _ - _ -__ __ -_ —Rp�Mulwe Telephone <br /> Tanks) <br /> Addteu _ _. RepreNnlNire -.----__ <br /> Telephone <br /> 2. OPERATOR N -f� <br /> ARf'0-A010,--L71J E._ -emLteLHwy. -.99,_ Mant_ec_a_, CA <br /> ame _ - <br /> telephone <br /> 3. REASON FOR To check {on ti.ghtne�s6 <br /> TEST __ —- - -- — -- -------- - <br /> (Explain Fully) - --- - -- - ---- - ------ -------------- ----------- <br /> 4. WHO REQUESTED Ron Mita Anco <br /> TEST AND WHEN "anp,p, Box 5811 San Mateo,""Cal✓i�onnia 94402 CpmpanrotAnuletlen ame <br /> a . <br /> Addeess ----- __-- ---- Telephone <br /> 5. WHO IS PAYING Arco Ron M,it ez .6am e <br /> FOR THIS TEST? fl"1Dlnr' re5'9Tr"' San Mateo, MtMa 94402 rine Telephone <br /> Belling Address City State <br /> Zip <br /> Attention of: Rn Yi PA Didet No. OfMt Instructions <br /> Identify by Detection Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED L <br /> Lo <br /> Cover Fills Vents Siphons Pum <br /> 7. INSTALLATION N `f Il Z. <br /> DATA ,� .•,,¢ <br /> North inside dnvewer. CwKft%,Black Top. Size,infill make,Dtop Suction,Remote, <br /> Hear of station,a%. Earth etc, tuba,Remote Fills Site.Manlfolded which tanks) Make It known <br /> 8. UNDERGROUND <br /> I:the water over the tank? <br /> WATER Depth to the Water table Yo // r p"/// ❑ Yes No <br /> 9. FILL-UP Tanks to be filled % �' Date Arranged by f <br /> Name Telephone <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 /> Company Name Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER q 54 <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 /> Teals wars mads on the above tank ayelsl B M accordance with test procedures prescribed for p�}/p�r <br /> 12. TEST RESULTS as detailed on attaehad test eharts with reruns as follows: '�TRI16 <br /> Tank Identdkation Tight Leakage Indicated Date Tested <br /> oy v a <br /> This le b ON"fMet Masa tank strstsRW were tasted on the date(s)shown.Those Indicated as"Tight"7.�O� <br /> the criteria estop <br /> 13. CERT FICATION Ow National Fire Protection Aeociation Pamphlet 329 <br /> Data is e . D3 C LCI -- <br /> I Testing Conuectot or Company. By.- <br /> 41481 <br /> y. anatur <br /> Sered w.of Thermal / - 41 48 T 1 367 s P- o Box 1220, TU e, CA �?775 <br />