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PLEASE PRINT <br />ata._C .or Tank -System Tip tn s Test <br />tie r2 EtQ = y <br />TANK TESTER - <br />1. <br />OWNER Propany ❑ <br />Tank(s) ❑ <br />- , ( <br />�7 Q K <br />ame - Address <br />Representative Telephone <br />Name Address <br />Representative Telephone <br />2. <br />OPERATOR <br />Name <br />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 of Affiliation Dale <br />Address Telephone <br />5. <br />WHO IS PAYING <br />FOR THIS TEST? <br />Company, Agency or Individual Person Authorizing <br />Title Telephone <br />Billing Address <br />Cily' State Zip <br />Attention of: Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />Al o -P <br />Capacity <br />Brand/Supplier <br />Grade <br />lZQ <br />Approx. Age <br />Steel/Fiberglass <br />o <br />x <br />i� <br />1a_INSTALLATION <br />ti�-� DATA <br />- <br />Location <br />ct`�t o n <br />North inside drivewij, <br />Rear of station, etc. <br />Cover <br />CSC <br />Concrete• Blstik Top, <br />Earth. etc. <br />Fills _ <br />v p :4v � .5 <br />. Size, Thefiff make, Drop <br />tubes. Remote Fills <br />Vents <br />- <br />Size. Manifolded <br />Siphons <br />, _ <br />Which tanks? <br />Pumps <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 />FILL -UP <br />ARRANGEMENTS, <br />Tanks to be filled hr. Date Arranged by <br />Extra product to "top off- and run TSTT. How and who to provide? Consider NO Lead. <br />Name _ Telephone .. <br />Terminal or other contact <br />for notice or inquiry <br />• Company <br />Name Telephone <br />10. <br />CONTRACTOR, <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 R—P jltP <br />as detailed on attached test charts with results as follows: �Ft <br />Tank Identification Tight Leakage Indicated Date Tested <br />o o <br />I 3 <br />aro <br />13. CERTIFICATION <br />/ Senal Np.ot Thermal <br />Sensa <br />This is to certity that these tank systems were tested on the dates) shown. Those indicated as "Tight- meet the criteria established by <br />the National Fire Protection Asociation Pamphlet 329. <br />T estrnp Comranm or Componr. By: Srpna rete <br />TeCh-C,ans Address , <br />