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air <br />t.wrt for Tank System Tighoss Test <br />petro Tde <br />•A,i.u.. <br />2. <br />OPERATOR <br />Name Addrasa <br />Telephone, <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />- <br />d. <br />WHO REQUESTED <br />)/ <br />62 <br />TEST AND WHEN <br />"'me This Company or Affiliation <br />Oat* <br />. <br />Address <br />Telephone <br />S. <br />WHO IS PAYING <br />' <br />FOR THIS TEST? <br />c rnparry. Agency or Individuai Parson Authorizing' Title <br />1 <br />Telephone <br />during Address City State <br />'of. <br />ZIO <br />.Attention Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />IRVi by it ti n <br />Ca itY <br />Br nd uppller <br />ade J <br />Appy . <br />St I/ berglsss <br />7, <br />INSTALLATION <br />DATA <br />Lova io� Cover Fills Yes Siphorws P ps <br />)�,,2r <br />� • �� �G� � . !�/ /T <br />North inside driveway, `^ onorete, BlackTop, Size, T! Suction, Remote, Y <br />Rear of station, art. Earth, etc. to emote f Size, Menlfoldsd Which to*#II Maks If known <br />is the water over the tank T <br />Depth to the Water table El Yas ' No <br />B. UNDERGROUND <br />WATER <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name <br />Extra product to "top off' and run TSTT. Now and who to provide? Consider NO Lead. <br />' <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 />I;J <br />11. <br />OTHER <br />INFORMATION,�__ <br />ENVIh v \: ; 8 k i7AI <br />I <br />OR REMARKS <br />FERN11 I /6ERVICE'S' <br />Additional information on any, items above. Officials or others to be advised when testing Is in progress or completed. Visitors or otriervers present <br />during test etc. <br />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedums proscribed for <br />as d*tailed on attached test charts with results as follows <br />Tighk Leak ge Indicated Date Tested <br />// <br />n1deo <br />13. RFI AT <br />e <br />Senai No. of Thermal <br />Sensor <br />This la to certify the a w leafed on the <br />the Nation ec n A phial 329. <br />Techniclans <br />meet the criteria established by <br />=O *— If <br />r or Company. B�gnature- „ <br />