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Data A. rt for Tank System Tighss � <br /> petro TIte MAR 0 <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property <br /> N IRUNTv PERMIT/SERVICES <br /> ❑ Name Address Representative Telephone <br /> Tank(s) <br /> Name Address Reoresentative Telephone <br /> 2. OPERATOR PMC LDNEST7AIR30350 S• Vl�. <br /> Name Address Telephone <br /> 3. REASON FOR MAi (4 <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company or Affiliation Oate <br /> • Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company,Agency or Individual Person Authorizing Title Telephone <br /> Billing Address City State Zip <br /> Attention ol: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED \rlESrof Qr-RQ 00 (26u01r1l E,K+D N OWfkl STEEL. <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION "n / <br /> DATA jf/LE CA�7N -311 .2 AAO,(45 yJGT/or� <br /> North Inside driveway, Concrete,Black Too. ke.Oroo Suction,Remote, <br /> Rear of station,etc. Earth,etc. tug ilh Size,Manifolded Which tanks? Make if known <br /> 8. UNDERGROUNDIs the water over the tank t <br /> WATER Depth to the Water table t 0 Yes No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP 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 /> COTOinY Name Telephone <br /> 10. CONTRACTOR. <br /> MECHANICS. <br /> any other contractor <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 in progress or completed.Visitors or observers present <br /> during test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for Petro jlte <br /> 12. TEST RESULTS as detailed on attached lest charts with results as follows: W hslla <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> IYA11- 4 V/ES -.DeloS E3 <br /> This Is to certify that these tank systems were tested on the date(s)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> 2 160401.dj n.9-7' are 1 9-z <br /> Da 1e Testing Contractor/°r Company. BY• Sign re <br /> /9-39 e_1y/.J 6!'Z iF 2SbC!X S9 - - <br /> Serial No.of Thermal Technicians Add,. <br /> sd <br /> Sensor <br />