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Dat Grrart for Tank System 1 h <br /> y fig l�-ess <br /> petro Tite MAR o 1 y <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property <br /> Nam• EN PERMIT/SERVICES <br /> Tank(l) Addrtal Reor•s•nuo.e <br /> T.r<pnone <br /> N•m• Address R•or.s•nta rive <br /> T•t•Dhon• <br /> 1. OPERATOR M NE 30 S. <br /> Name Address <br /> T.ieonon• <br /> 3- REASON FOR _ 1YlA(N INANC,� <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN "'m' Title COTD+mr or Affiliation <br /> Dal. <br /> r Address T.11DnD n. <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Agency or Individual Person Aufhoriting fill. Tel.ohDn. <br /> (filling Address City State <br /> Attention ol; Order No. Other tnsuvclions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED \AEs'roF OFRi p LwN LES N owl STEEL <br /> Location Cover Fills Vents Siphones Pumps <br /> 1. INSTALLATION y(T >o <br /> DATA <br /> E ZA,E rs/ �'' 2'' .4 A0,/—Z- �e row/ <br /> North Instd•diivewsy, Concrete Black Too. S' eke.Drop Suction.Remott, <br /> Rear of iia lion,etc. Earth,tic. tug ill. Sire.Manifold.d which tanks 1 Mak•if krip—n <br /> 8. UNDERGROUND '/ Is the water over the tank 7 <br /> WATER Depth to the Water table 'DT + El Yes Q No <br /> 9. FILL-UP Tanks to be filled hr. Date Arranged by <br /> Name T+Itpnon• <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide j Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company N.me Teltonone <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 were made on the above lank systems in accordance with lest procedures prescribed for pe1r0 T11P <br /> 11. TEST RESULTS as detailed on attached lest charts with results as follows: w..hIlla <br /> Tank Identification Tight Leakage Indicated Date Tested <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 /> 13. CERTIFICATION the National Fire Protection Asoclalion Pamphlet 329. <br /> o:. ' n r l�odri.�� x��r j . <br /> T•sling C0.11.0.�r Como•nr. 8y: Sign <br /> /9_39 A4ZI dlE/ C'dM-1- 2_ '�/ r(i,�,� r ,c/s1/-w Z,4 ss� <br /> S-1 Nd of Thermal T•C hniU•n• . Ado.• <br /> Sensor <br />