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DataAart for Tank System Tigil cess Test <br /> petro Titer _�_ e <br /> UE 6PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ <br /> Tank(s) <br /> ❑ Na Address Representative TetaphoM <br /> L��� .� � <br /> Name Address Representative Tetaphone <br /> 2. OPERATOR ' ic' 7 `t " 1.. ct/ ,�/J ��Tc'eit>ct• <br /> Name Address <br /> Telephone <br /> 3. REASON FOR <br /> TEST G3T /�'c ti i✓ _ . <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company or Affiliation oere <br /> Address <br /> J elephona <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Agency or Individual Person Authorizing Title —Telephone <br /> Billing Address City State Zip <br /> Attention of; Older No Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Ape Steel/Fiberglass <br /> 6. TANK(S) INVOLVED7 S�G C l-+ -Z'e/ <br /> L cation Cover Fills Vents Siphones Pumps <br /> ,. DATAALLATION -� e* r l ,, Z -� : V 4;�­ _ <br /> North inside driveway. Concrete.Black Top. Site,Tildnl make.Drop Suction.Remote. <br /> Rear of station.etc. Earth.etc. tubes.Remote Fills Sire,Manitolded Which tanks? Make il known <br /> 8. UNDERGROUND is the water over the tank 1 <br /> WATER Depth to the Water table ❑ yes ❑ No <br /> Tanks to be filled hr. Date Ad by <br /> 9. FILL-UP Arranged 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 /> 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 tank systems in accordance with test procedures prescribed for1r0 jig <br /> 12. TEST RESULTS aattached <br /> s detailed on rt <br /> test chants with results as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> id ,J _ ire VC .C. ) <br /> T <br /> i <br /> This is to certify that these tank systems were tested on the da s shown. osel IndiF u"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asocistion Pamphlet S>tg. <br /> f� „'erT estmo�ontrai or om n . �0�`Signature <br /> F. U. » I <br /> Serial No of Thermal Technicians CA W <br /> Sensor l.,;,itl� <br />