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4 <br />Data *rt for Tank System Tig*ess Test <br />pttrO TItP <br />PLEASE PRINT TANK TESTER <br />fe-ex. <br />1. OWNER Property <br />{(M A-1 <br />Name <br />Tank(s) Ad RePresemNrve <br />Address <br />2. OPERATOR <br />Name <br />Telephone <br />Yolephone <br />3. <br />REASON FOR <br />lesufC.njia oro Company By: <br />TEST <br />7e h nicions <br />(Explain Fully) <br />Add -s. <br />4. <br />WHO REOUESTED <br />TEST AND WHEN <br />Name Me Company of Affiliation Out. <br />Address Telephone <br />5. <br />WHO IS PAYING <br />�Aul.o�wln <br />FOR THIS TEST? <br />6-0m Agency of Individual <br />Tel®h­. ne- <br />filing Address — — — — — -- ------- -- <br />Attention of: Older No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify b 7hon <br />Capacity <br />Brand/Su pher <br />.7. <br />Approx. Age <br />Steel/F glat's <br />7. <br />INSTALLATION <br />Location <br />Cover r <br />Fills_ <br />Vents <br />Siphones <br />Pumps <br />DATA <br />Inside driveway, <br />NorthSiz <br />Real of station. etc. <br />Concrete, Black Top, <br />Earth. etc. I <br />e, Tiletill make, Drop <br />tubes, Remote Fills <br />Size. Mandolded- <br />Which tanks? <br />Suction, Reroute, <br />Make it known <br />8. <br />UNDERGROUNDat <br />IA)'Is the war over the tank <br />WATER <br />Depth to the water table ir 1IL"'t Yes No <br />9. <br />FILL -UP <br />Tanks to be filled _��Jwr. 2_ "to Arranged by <br />ARRANGEMENTS <br />E Name Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />10. <br />CONTRACTOR, <br />_7 A <br />MECHANICS, <br />i <br />any other contractor <br />involved <br />11. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />—information —above. <br />Additional on any i—tems Officials or others to be advised when testing is in progress of completed Visitors or observers present <br />during test etc. <br />Tests were made on the above tank systems in accordance with test procedures proscribed for Imm-AIRPI—e <br />12. <br />TEST RESULTS <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />A6_X- <br />13. <br />CERTIFICATION <br />This is to cortity, that the" tank systems were tested on the date(s) shown. Those indicated as "Tight" meet the criteria established by <br />the National Fire Protection Asociation Pamphlet 329 <br />sic _ 1 k <br />JLI rt I 1!�*,/ . . , 77 ,-L.. 4. <br />r7'7� <br />lesufC.njia oro Company By: <br />Swat No. of Thermal'' <br />Sensor <br />7e h nicions <br />r <br />Add -s. <br />