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warn <br />Data Chart for Tank System Tig?tness Test <br />petrO Tit <br />PLEASE PRINT TANK TESTER <br />1. OWNER Propeny <br />Tanks) ❑ % <br />N / 7 Address Representative telephone <br />❑ "� %� <br />eme �= Address Representative Telephone <br />2. <br />OPERATOR <br />Name- <br />lil <br />Addrsss <br />41A_1 <br />Telephone <br />3. <br />REASON FOR <br />TEST <br />r <br />(Explain Fully) <br />4. <br />WHO REOUESTEO <br />TEST AND WHEN <br />Name <br />TUle <br />Company or AfPowuon Dale <br />Vents <br />Size. Manifolded <br />Siphonas <br />/ <br />Which tanks? <br />A <br />Addle" <br />t Telephone <br />5. <br />WHO IS PAYING <br />FOR THIS TEST? <br />Company, Agency or Individual <br />Billing Address <br />Attention of: <br />Poison Authontin <br />City <br />Order No. <br />Title Telephone <br />State Zip <br />Omer Inas—h.ne <br />entdy by tae G n <br />6. TANK(S) INVOLVED <br />Ce �cny <br />if✓ <br />Br �n�d�f�upplror <br />�`f3�% /L' <br />ado <br />/, _� <br />ApprO . (tgo <br />/f <br />St a berglass <br />Locatio w <br />7. INSTALLATION <br />DATA <br />North inside driveway, <br />Rsar of station, etc. <br />Cover <br />�,` <br />�� <1 <br />oncrete, Black Top, <br />Earth, etc. <br />Fills <br />�� <br />w <br />d <br />Size, TiteImpke. j1 <br />tube emote Fdla <br />Vents <br />Size. Manifolded <br />Siphonas <br />/ <br />Which tanks? <br />Pu ps <br />Suction. Remote, <br />Make if known <br />C. UNUMMUUNU Is the water over the tank <br />WATER Depth to the water table ❑ 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 Load. <br />Terminal or other contact ' <br />for notice or inquiry <br />Company 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 won made on the above tank systems in accordance with test procedures prescribed for f, x3;— <br />12. TEST RESULTS . as detailed on attached test charts with results as follows: ' i i'° <br />ntfa <br />I�deiPicatiop>/ ��',-7I— Tigh I Leakpge Indicated ^ I Oats Tested_ <br />This is to certify t thea AWAY* <br />13. , :Rj F1 ATV the Nations r etc n AiDeiai <br />t_ / <br />Sxtal No of Thermal Technicians <br />Senior <br />tested on the <br />AM 329. <br />Igh(;' meet the criteria established by <br />Testing Contractor or Company. By: Signature <br />Address <br />