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Data Chart for Tank system Tightness Test <br />PLEASE PRINT <br />1. OWNER Property <br />Tank (s) <br />SfZrrj S N PST <br />rZ O J rl <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identity by Direction <br />Name Address Representative <br />Telephone <br />Name Address Representative <br />Telephone <br />2. OPERATOR <br />r <br />Name Address <br />Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />1:t <br />e i2 LFdhan <br />J Q ,,j!K SO 1-4 <br />7/1 NG - <br />e, f f /J ✓ ,j ]PP_,, n 1,1 Cr, <br />4 <br />t R : • <br />F <br />4. WHO REQUESTED <br />TEST AND WHEN <br />�� <br />Name Title Company or Affiliation <br />Date <br />12. SENSOR <br />CERTIFICATION <br />Date <br />Serial No. of Thermal <br />Sensor <br />13. This is to certify that dm* tank systems were tested on the dates) shown. Those Indicated as -Hybl" meet the establbhed by the <br />National Flnod <br />re Protection Aatl3291. <br />on Pamphiet <br />Technicians <br />PHILIP F. DELGADILI� Paradiso Constructs n Co <br />L,!k1 <br />122510940 Testing Contractor or Company. By Ignetur <br />Certification //� 9220 "G" Street, Oakland, CA 94603 <br />2 STA 5P (A.. Address <br />Certification . 12 — 10 Ss <br />PN6827 <br />Address <br />Telephone <br />5. TANK INVOLVED <br />Use additional lines <br />for manifolded tanks <br />Identity by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />n <br />R ' <br />' �— <br />4 <br />t R : • <br />F <br />6. INSTALLATION <br />DATA <br />Location <br />ts.1L1-r Cc. P-jr-r, <br />F r <br />North inside driveway. <br />Rear of station, etc. <br />Cover <br />lib G <br />Concrete, Black Top. <br />Earth, etc. <br />Fills <br />/ <br />Size, Titefill make. Drop' <br />tubes, Remote Fills Po <br />Vents <br />Size, Manifolded A.10 <br />Siphons <br />Which tanks? <br />Pumps <br />F tC. <br />It r�T <br />Suction, Remote. <br />Make if known <br />7. UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table +' ❑ Yes l..Q.N. <br />6. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name <br />Extra product to "top off' and run tank tester. How and who to provide? Consider NO Lead. <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />Paradiso Construction Co. <br />10. 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 during test, etc. <br />11. TEST RESULTS <br />Testa were made onast�� ed on oak ed Inst char its with withtestas follows: prescribed for <br />Tank Identification Tight Leakage Indicated <br />Date Tested <br /># 3 E AR 0 2- 6-P <br />9-2,6-96 <br />12. SENSOR <br />CERTIFICATION <br />Date <br />Serial No. of Thermal <br />Sensor <br />13. This is to certify that dm* tank systems were tested on the dates) shown. Those Indicated as -Hybl" meet the establbhed by the <br />National Flnod <br />re Protection Aatl3291. <br />on Pamphiet <br />Technicians <br />PHILIP F. DELGADILI� Paradiso Constructs n Co <br />L,!k1 <br />122510940 Testing Contractor or Company. By Ignetur <br />Certification //� 9220 "G" Street, Oakland, CA 94603 <br />2 STA 5P (A.. Address <br />Certification . 12 — 10 Ss <br />PN6827 <br />