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Data C_irt for Tank System Tigh' 'ss Test <br /> petro Titp <br /> PLEASE PRINT TANK TER <br /> 1. OWNER Property <br /> Tank(s) ® Aadrou y-e; ire .. <br /> TNephona <br /> Neme /.Addrae <br /> 2. OPERATOR Aapreaanpnve - TalaDhons <br /> Name Aodrau <br /> 3. REASON FOR <br /> TEST l 2NiR <br /> (Explain Fully) .[9 isy <br /> 4. WHO REQUESTED <br /> TEST AND WHEN NsmewF Tine <br /> i�N J Company or AMillauon par.- <br /> 5. <br /> m5. WHO IS PAYING <br /> FOR THIS TEST? Company,Aoancy or Individual Person Authorizing <br /> Title Telephone <br /> Billing Addrau City <br /> SUN Zip <br /> AMntbn oF. Drder No. Other Instwctioe <br /> Identify by Direction Capacity Brand/Supplier tGradeAppmx.Age Stasl/Fiberglau6. TANKS) INVOLVED A /97 Z .STS F <br /> Location Cover Fills Vents Siphon" Pumps <br /> 7. INSTALLATION SUu'lloi 2Gm.- <br /> DATA CO�tC2c% -e/ll c �, tiU �- <br /> .Zsiatio � <br /> North Inside dMeway. CmCftft,Black Top, Size.Tlteflll make,Drop <br /> pear of station,etc. Earth,atc. tube,Remote Fills Size.Manifolded Sucuon,Remota, <br /> Which Ynka i Mate if known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table /�/U n ti 0 /�t D El Yes ® No <br /> 9. FILL-UP Tanks to be filled hr. Date Aminged by <br /> ARRANGEMENTS Extra evade<t to"top off'and run TSTT. How and who to provide? Consider NO Lead. Name T°lephon° <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Neme Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, /->, 0 <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 f }p <br /> 12. TEST RESULTS as detailed on atlsched test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Dau Tested <br /> 13. CERTIFICATION This is to certify that these tank systems were tested on the cialba )Mown.Those indicated as"Tight"meat the criteria established by <br /> the NetiogaIlm Protection Asociation Pamphlet 329. <br /> Data <br /> Tesdnp Contn<tor or company. By: Slapawre <br /> /03? C <br /> SerW No. at Thermal Technicians Addreu -" <br /> Sensor <br />