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Data -_ hart for Tank System Tig..ness Test <br /> Rthr Trap <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER 71 on!dlff Oi y2J— T N /O <br /> ® Name Addross R4prosentadvs Telephone <br /> Tank(s) <br /> Name Address Representative Tslephene <br /> 2. OPERATOR <br /> Name Address <br /> Telephone <br /> 3. REASON FOR <br /> TEST <br /> i (Explain Fully) <br /> 4. WHO REOUESTEO o F <br /> TEST AND WHEN N°"° Title Company Or AHiliadon Date <br /> Address Telephone <br /> I <br /> 5. WHO IS PAYINGo/Y ca <br /> FOR THIS TEST? Company.Agency at Individual Person Authorizing This Telephone <br /> Billing Address City State 21p <br /> Mention of: Order No... - Other hntrucllons - <br /> Identify by Direction Capacity Brand/Supplier - Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED /Z o00 Reg /9,7F <br /> ♦o. 97 PE.F <br /> Location Cover Fills Vents Siphoning Pumps <br /> 7. INSALLATION .50 hof ev^e°/1e% </i/ ail ti0 Xeroolw <br /> DAT <br /> �"SlAvkll Gi/d.aaco <br /> Nonh inside driveway, Concrete.Black Top. Size,Titsfill mese,Drop Suction,Remote, <br /> Ree,W rVi ion.etc. Earth,etc. tubes,Remote Fills Size.Manifolded Which ranks 7 Make i1 known <br /> 6.. UNDERGROUND / is the water over the tank? <br /> WATER Depth to the Water-table /�V 'W H�O yes No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Teroohona <br /> ARRANGEMENTS Extra product to'-top off'and run TSTT. How and who to provide 7 Consider NO Lead. <br /> Terminal or other contact - <br /> for notice or inquiry <br /> Company Nam° Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, Td�i <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 /> Teat seem made on the above tank systems in accordance with test procedures prescribed forlro 11P <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: T <br /> Tank Identification Tight Leakage Indicated — Date Tested <br /> 404,ge S <br /> This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight"meet the er(tsria established by <br /> 13. CERTIFICATION the heeDggal Fire Protection Asociation Pamphlet 329. <br /> Aim `QL� Ca <br /> Date <br /> Tasting ConbactOror LOmpanY. dy: SigOaNu y� <br /> /43? 9 y r a, a93? w, co.hat o �gsw <br /> Serial No.of Thermal Techhicians Address <br /> se"'" <br />