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Dataaart for Tank System Tic(ess Test <br /> petro Titer <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property El <br /> c fry n� <br /> Name <br /> Tank(s) Address Representative Telephone <br /> S AJ <br /> Name Address Representative <br /> Telephone <br /> 2. OPERATOR t <br /> Name Address <br /> Telephone <br /> 3. REASON FOR N Li <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED 7r• <br /> TEST AND WHEN Name Title Company or Affiliation <br /> Date <br /> Address Z5 6 <br /> Telephone <br /> 5. WHO IS PAYINGc c t <br /> FOR THIS TEST? Company,Ape cy or Individual Person Authorizing Title <br /> Telephone <br /> Billing Address City State <br /> ZIP <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6, TANK(S) INVOLVED k4d It :l` <br /> Location Cover Fills Vents Siphones Pums <br /> 7. INSTALLATION -3�f As t o a A!o L j C 1- 2 r r P <br /> DATA S,� f <br /> North inside driveway, Concrete,Black Top, Size,Titefill make,Drop <br /> Rear of station,etc. Earth,etc. tubes,Remote fills Size,Manifolded Suction,Remote, <br /> Which tanks 7 Make if known <br /> 8. UNDERGROUND /J Is the water over the tank T <br /> WATER Depth to the Water table v l n tj )_?' <br /> 11 Yes ® No <br /> 9. FILL-UP Tanks to be filled hr. Date Arranged by <br /> ARRANGEMENTSName Telephone <br /> 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 for fro ItP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: res,EaT <br /> Tank Identification Tight-, -— Leakage Indicated Date Tested <br /> ye S , n 5- <br /> 13. CERTIFICATION This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight"meet the criteria established by <br /> the National Fire Protection Asoclation Pamphlet 329. <br /> - <br /> la-,1-= <br /> Tesh g C.l.Contr,i ko-4 J �A� <br /> actor or compan y. Signature <br /> Serial No.of Thermal �V�� S► .^Cpl� S f t:s� if-jL"W <br /> Technicians <br /> Sensor Address <br />