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ua[a unaeor i anK system <br />petro Tite <br />PLEASE PRINT / ' 1193 TANK TESTER <br />igntnoftest, F.. <br />1. <br />OWNER Property [ <br />T <br />Aevtolvi 2,36 11,4m <br />LdNe_ LoAov C,9. <br />Tank(s) <br />Name <br />Address Representative <br />Telephone <br />Name Address Representative <br />Telephone <br />2. <br />OPERATOR <br />S <br />Name <br />Address <br />Telephone <br />3. <br />REASON FOR <br />TEST <br />lj /Q •� �- <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />r N <br />TEST AND WHEN <br />Name <br />Tips Company or Affiliation <br />oats <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />C n/ <br />FOR THIS TEST? <br />Company. Agency or Individual <br />Person Authorizing Title <br />Telephone <br />Billing Address City State <br />Zip <br />Attention of: <br />Order No. other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />Capacity <br />d <br />Brand/Supplier <br />-Che vaw:•tel <br />Grade <br />/ <br />Approx. Age <br />Steel/Fiberglass <br />5�c e <br />7. <br />INSTALLATION <br />DATA <br />Location <br />6404 0f- <br />57-,? 17fwnl <br />Nonhinside driveway, <br />Rear of station, etc. <br />Cover <br />CCVlw%f <br />Concrete. Black Top. <br />Earth, eta <br />Fills <br />3 "ho-// <br />&WlAe <br />Size, Thelia make, Drop <br />tubes, Remote Fills <br />Vents <br />11 <br />Size, Manaolded <br />Siphons <br />� <br />Which tanks? <br />Pumps <br />/ <br />Suction, Remote. <br />Make if known <br />8. <br />UNDERGROUNDGGi�t <br />WATER <br />�Cy L Is the water over the tank ? <br />Depth to the Water table he &m 7.-4&ks E] Yes WN. <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Hanged by <br />Name <br />Extra product to **top off' and run TSTT. How and who to provide? Consider NO Lead. <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />10. <br />CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />SCO / fir_ Q A0 kl <br />11. <br />OTHER <br />6aaA /�S <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 />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for PPtf01P <br />as detailed on attached test charts with results as follows: j r€SFa <br />Tank Identification Tight Leakage Indicated Date Tested <br />Lvr,-,;-Ac ad Mwt Yes}• <br />06 9 6 <br />07 <br />13. CERTIFICATION <br />11-aS-$g' <br />Date <br />18317 <br />Sena► No. of Thermal <br />Sensor <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 />the National Fire Protection Asociation Pamphlet 329. <br />Testing Con rector or Company. By: Signal <br />9 /%lAIA� -i rST ORl;1_4.vt-1 <br />Technicians iAddress <br />�KS� J3 �/-333 <br />