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_;ata Chart for Tank Sy,..em Tightness Test <br /> PLCASE PRINT <br /> 1, OWNER Pmpeny C {/��✓ �/i re i 1p"jai r ✓ 1� f f :Jr S�sc/< r . ��cr. <br /> Addl.0 R.pmenlWq TIp lone <br /> T.nk:sl J <br /> Nnn:e Audi. Npmenleuw lalaohdne <br /> 2. OPERATOR <br /> Name ACdrw TelpMal <br /> 3 REASON FOR <br /> TEST <br /> IEspla:n FWIyl <br /> 4, WHO REQUESTED <br /> TEST AND WHEN Nene n. Company or Aniltalion Dark <br /> Address Telephone <br /> IUenfify bs DnrC,oh Cal ennd,SOppha Grid. Approa,Ape SIalBFlberglass <br /> 5. TANK INVOLVED Yf/ hlr d jlfi��LivCt �r S <br /> for addition,[Il nse <br /> for meMblaed Tents <br /> L : n COrp Fills Varna SipMnO Pumps <br /> 6. INSTALLATION eta <br /> DATA G„r, • <br /> Nona Inside dnvewey, Conc,ete.Buct Top. Sue,Thefilt make,Drop Suelon,permits,. <br /> Fear of natio,ate. El etc. I tubes.Remo le Fills I &I.,Man001ded I Which Iade• I Mab H known <br /> 7. UNDERGROUND 1.the water over tints tank? <br /> WATER Depth to His W.I.,table Deal ❑No <br /> Tanks lob filled h, Data Arranged by <br /> 8. PILE-UP Name Telephone <br /> ARRANGEMENTS Extra producl to lop olrand run tank Iselin, teow and who to provide' Consider NO Load. <br /> Terminal or otter wharf <br /> lo,nouce or mOmry <br /> Company Name Telephone <br /> 9. CONTRACTOR, <br /> MECHANICS, <br /> any other conlrector <br /> invomed --- <br /> 10 OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Addtional edormeton on any nems aWve OtP4als or Others:o be aovleed'ehen!esling is In proq,aes or compleled V:siloo or oEsaven presenl dunhg test.Mc. <br /> Tagil.Wan mad,on the above lank system. In eccordence with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on atlached test charte With rewth.Iollows: <br /> Tank MenbbGilion Tigs Leakage bCultad Data Tested <br /> - <br /> ii•S P.,4� j�`S � ti <br /> I <br /> 12. SENSOR 13.That is to e.noy sew weeks tkslaa syst«ne were tesled on the deft.(.)shown Those W.dlealed y-NW meet the vlterte es+abltenw by the <br /> CERTIFICATION National Fire protection AsoccL@toal p'mphM 3X <br /> Tp�hncuM <br /> Dae I (`(.etb��l l�"�rttd'e 1�✓b/.K/,n CdX t / ��r't'ltf� <br /> [T(wlmgContrnvpbr a Lampary. try <br /> /BIp�Nun—�—" <br /> yno.1Tnarmel CMleea'cn I 41 <br /> AdO,aal <br /> LM111fanm <br /> 0 _ _ e IhNea„ <br />