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ata hart for Tank System Tight—ness Test <br />DC <br />etrO TIte <br />{,._PLEASE PRINT TANK TESTER - <br />1. OWNER P,.,.,,, 0 <br />Tank(s) X <br />Name Address r7 Ri,p—mative <br />Name <br />2. <br />OPERATOR <br />141504/ E: <br />Name Telephone <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />M9 <br />TEST AND WHEN <br />Name Title OmPany of Affiliation Date <br />Address Telephone <br />5. <br />WHO IS PAYING <br />eOy72: ���o <br />FOR THIS TEST? <br />Company. Aoency or Individual Pelson AuthonzinW Title TO none <br />t Ju 51 <br />I <br />usiling-Address City <br />•Attention <br />of: _0_1de_f,N__o­. —Other —Insituct-ions <br />Identify by D traction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/ Fiberglass <br />6. <br />TANK(S) INVOLVED <br />7-- / <br />Location <br />Cover <br />Fills <br />Vents <br />Siphones <br />Pumps <br />J. <br />INSTALLATION <br />50.4-rti- 0 -IF - <br />-if <br />exe_4e <br />DATA <br />FF -0-r off -C <br />4:�o <br />Z <br />North inside driveway. <br />Real of station, etc. <br />Concrete. Black Top, <br />Earth, etc. <br />Size, T,tafill make, Drop <br />tubes, Remote Fills <br />Size. Manif olded <br />which tanks? <br />Suction. Remote. <br />Make it known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank ? <br />Depth <br />to the Water table Ll Yes El No <br />Tanks to be filled 'JAY11 hr. �Date <br />9. <br />FILL -UP <br />Arranged by <br />ARRANGEMENTS <br />Name Teleph.,,. <br />Extra product to "top off" and run TSTT. How and who to provide l Consider NO Lead. <br />Terminal Or other Contact <br />for notice or inquiry <br />Company Nama Telephone <br />10. <br />CONTRACTOR,- <br />-- <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 />Tests were made on the above tank systems' in accordance with test procedures prescribed for P2t_t_r0 TLt-(, <br />12. <br />TEST RESULTS, <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />--- — -- <br />This Is to cortily that these tank systems were tested on the date(s) shown. Those indicated as "Tight" meet Ilia criteria established by <br />13, CERTIFICATION the National Fire Protection Asociation Pamphlet 329, <br />Crj Are k-56 <br />Testing Contractor or Cbr,,li—y. by 'IF, <br />/311 <br />ojvgrict— :!�: <br />-Technicians jv <br />Serial No. of Thermal Address <br />Sensor 4 <br />Z <br />