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11 <br /> r 4 <br /> Data Chart for Tank System Tightness <br /> PLEASE PRINT <br /> 1. OWNER Property ' E • LI"mil 2 oZ _-,z-?' -v <br /> Tank(s)L(d__ Name H�rr) tatvp Telephone <br /> 4 S AO w <br /> I <br /> Name Address Representative Telephone <br /> 2, OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR /VrL %' 7-2E57- <br /> TEST <br /> "2'STEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED `1�e' /� , ;/ f""� �t S 7, ; d f r tr 24 <br /> TEST AND WHEN Name Tittle company or Affiliation Date <br /> f ` 4 <br /> Address Telephone <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Stse/Fiberglase <br /> 5. TANK INVOLVED 0' !,fin �/ lee �e b � 7-F. 4, <br /> Use additional lines <br /> for manifolded tanks r r <br /> Location Sm TAt( Cover Fills Vents Siphones Pumps <br /> 6. DATA INSTALLATION ®,F r?r/"t 'P-jlr // <br /> U,.4 7. <br /> ,09 af.;e <br /> "- - North inside driveway. Concrete,Black Top, Size,Titefill make.Drop Suction,Remote, <br /> Rear of station,etc Earth,etc. tubas.Remote Fills Size,Manlfolded Which tanks? Make it known <br /> 7. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table �� Yes N11 No <br /> Tanks to be filled UU hr. �'JQ ate Arranged by <br /> 8. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to'lop off'and run tank tester. How and who to provide? Consider NO Lead. <br /> a- 6a. 1.61 /'2-6- _ <br /> Terminal or other contact 1 1" r <br /> for notice or inquiry_ if r d�7-2e ,l <br /> Company Name Telephone <br /> 9. CONTRACTOR, J t-rj:;e .m tie A&-. rgc_ r �� ,► 4 "•vl r�" <br /> MECHANICS, Ife <br /> any other contractor <br /> Involved <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 comped.Visitors or ota®nrers present during test,etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on attached test charts with resufts as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> i u/ 12 G <br /> 12. SENSOR 13.This Is to cartery that these tank systems were tested on the date(*)shown.Those lisdIcated as meet the cdtwb established by the <br /> CERTIFICATION a++�Fire Protectlon 91 <br /> tet 32 <br /> ® Technicians i <br /> .� i Data <br /> !'v�. t r `�--^-A75,-'1 i/14'2'!�L "r' CITY Df' aw <br /> l/�! !y �!y Testing Contractor or Company. By: Signature <br /> Serial No.of Thermal Certification If <br /> Sensor <br /> Address <br /> 2 <br /> Certification 0 PN6827 <br />