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Data CAI for Tank System TighAs Test <br /> F*jR� <br /> r <br /> PLEASE PAINT TANK TESTER <br /> 1. OWNER Property ❑ G1 f�=/ <br /> ❑ Na IFpe Address Representative Telephone <br /> Tank(s) <br /> Name Address Representative Telephone <br /> 2. OPERATOR D L <br /> Name Address Telephone <br /> 3. REASON FOR ` <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED Ll <br /> TEST AND WHEN Name Title tompany or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Agency or Individual Parson Authorizing OF Title Telephone <br /> Billing Address city State Zip <br /> Attention of: Order No. Other Instructions <br /> dentify by Direction Capacity Brand/Supplier Grade Approx.Age Steel fiberglass <br /> 6. TANK(S) INVOLVED <br /> Location CoverFills Vents Siphons Pumps <br /> 7. INSTALLATION ,� fZ�t.: ,�,� ®� <br /> DATA <br /> ,, 1 <br /> North inside driveway. Concrete.Black Top, Size,Titer Suction.Remote. <br /> Rear of station,etc. Earth,etc. tubs emote Fills Size,Manifolded Which tanks? Make if known <br /> 8. UNDERGROUND Is the water over the tank <br /> WATER Depth to the Water table ❑ res LK 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 Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> Iother 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 tasting is in progress or completed.Visitors or observers present <br /> during test etc. <br /> Tests weremedia on the above tank systems in accordance with last procedures prescribed for ftp jltP <br /> 12. TEST RESULTS as detailed on aftc1ted test charts with results as follows: earn: <br /> Tank Identification Tighl Leakage Indicated of rE Date Tested <br /> GLL <br /> This le to certify that k system: ere tested on the 'W as T• t, if established by <br /> 13. CERTIFICATION theNational R Asocl n amphlet 329. IF, y,I RIC <br /> . 7 Oat_. e _ 4esting tractor or Company. By: Signature <br /> 7 <br /> Ssral No.of Tttannal Technicians Address <br /> Senses <br />