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PLEASE PRINT <br />I. OWNER property <br />Tank(s) <br />2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED <br />TEST AND WHEN <br />5. WHO IS PAYING <br />FOR THIS TEST? <br />6. TANK(S) INVOLVED <br />7. INSTALLATION <br />DATA <br />8. UNDERGROUND <br />WATER <br />Data Cort for Tank System TighAss Test <br />petro Tote <br />TANK TESTER <br />Name <br />Company. Agency or Individual <br />filling Address <br />Attention ot: <br />Identify by Direction Capacity <br />STJT/ $ bo O <br />S <br />Brand/Supplier Grade <br />Approx. Age <br />Steel/Fibare ass <br />s <br />w� <br />Vents <br />tN.nhl�kld. <br />L:T <br />Z;veway,Titetill <br />Pumps <br />etc.es, <br />make, Drop <br />Suction, Remote, <br />Make it known <br />Is the water over the tank 7 <br />El Yes <br />Remota Fills <br />Size. Menllolded <br />Depth to the Water table <br />11 <br />MECHANICS, <br />Approx. Age <br />Steel/Fibare ass <br />ARRANGEMENTS <br />Extra product to "top off" and run TSTT. How and who to provide 7 Consider NO Lead. Nemo <br />Telephone <br />Siphons <br />Pumps <br />Which tents i <br />Suction, Remote, <br />Make it known <br />Is the water over the tank 7 <br />El Yes <br />11 No <br />9. FILL -UP <br />Tanks to be filled hr. Date Arranged by <br />ARRANGEMENTS <br />Extra product to "top off" and run TSTT. How and who to provide 7 Consider NO Lead. Nemo <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />10. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />11 OTHER -: 1 <br />INFORMATION <br />r ' OR REMARKS ; <br />i <br />:O t- <br />Additional information on any items above. Officials or others to be advised when testing is in progress or <br />timing test etc. <br />completed. Visitors or observers present <br />QL <br />._ -TESTRESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for <br />as detailed <br />Pp}FO TI}P <br />on attached test charts with results as follows: <br />wi..vsns <br />< t— - <br />< - <br />Tank Identification Tight <br />9 Leakage Indicated <br />S <br />�UT� <br />Date Tested <br />to <br />-ar- <br />This is to certify that these tank systems were tested on the date(,) shown. Those Indicated as "Tight" meet the <br />13. CERTIFICATION criteria established by <br />the National Fire Protection Asocla ion Pamphlet 329. <br />/I-d.r-Fri <br />Dare <br />�S�0 Testing Conuamor or COmWpy. By: S;Bnalure <br />S nal No. of Thermal Techmonana <br />Sensor Address <br />