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F <br />PLEASE PRINT <br />Data rt for Tank system TigAess Test <br />Pt,t► <br />TANK TESTER <br />ro vii 44/83 <br />7 Name Address Representative Telephone <br />Name Address Representative Teleohnne <br />2. <br />OPERATOR <br />C23(o N �a <br />Name Address <br />Telephone. <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Name Title Company or Affiliation Date <br />5. <br />WHO IS PAYING <br />Address <br />Telephone <br />FOR THIS TEST? <br />Company, Agency or individual Person Authorizing <br />Title Telephone <br />Billing Address City <br />State Zip <br />Attention of: Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass, <br />f ,-04JIL <br />/C7000 <br />e <br />I- <br />Ad- C0144, <br />Ode <br />fie-( <br />7 <br />INSTALLATION <br />AT <br />Location <br />North inside drMbway, <br />Rear of station, etc. <br />Cover <br />Cen eK& <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />a •• <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Vents <br />CP .r <br />Size, Manifolded <br />Siphons <br />f <br />Which tanks? <br />Pumps <br />/t,►�t s7�* <br />Suction, Remote, <br />Make if known <br />8. <br />UNDERGROUND <br />WATER <br />Depth to the Water table <br />Is the water over the tank? <br />Yes No <br />9. <br />PILE-UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name Telephone <br />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. <br />CONTRACTOR, <br />�"�'ufn , Cnrt�aL so2`/ PO f ez� M <br />�^9 / <br />6s /0°'~ 6tPK <br />MECHANICS, <br />any other contractor <br />involved <br />11. <br />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 />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for Ptptro j'Ite <br />as detailed on attached test charts with results as follows: UN=T <br />Tank Identification Tight Leakage Indicated Date Tested <br />la <br />�`.,3 -L✓4s�- e.s 0aa G. PX. <br />-84. <br />This is to certify that these tank systems were tested on the date(s) <br />13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br />Date <br />J t t,v1 �"r:STttalst.a <br />Serial No. of Thermal Technicians <br />Sensor <br />indicated as ' ght" set the iteria established by <br />a�, uu, �_ V-,_ - <br />actor or Compa y. 8y: Sig re <br />Addto <br />