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Y Data %..Aart for Tank System _.ess Test <br /> petro Tate <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER PrOpeny <br /> Tanks) ® ,Name Address— <br /> Tai Telephone <br /> Noma Atldreaq U Representative Telephone <br /> 2. OPERATOR <br /> Noma Address Telephone <br /> 3. REASON FOR <br /> TEST / fG�� r� a <br /> (Explain Fully) if <br /> 4. WHO REQUESTED 17 <br /> TEST AND WHEN Nams Till. Company or ARlliatlon <br /> Date <br /> Address Telephone <br /> 5. WHO IS PAYING T C C <br /> FOR THIS TESTI ComwnY.Agony or lnmvitlual Parson Amhorhlnp <br /> This Telephone <br /> Billing Add. city sia 21p <br /> Attention.,: Ortler No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Stall/Fiberglass <br /> 6. TANK(S) INVOLVED i Ii 72 0 .P , / 7 'T !rL <br /> Location Cover Fills Vents Siphons Pumps <br /> 7. INSTALLATION Sou�(r,o< Cv.lc, is <br /> DATA <br /> /fa�wco <br /> North Inside driveway, Concrete,Black Top. Size.Titefill make,Drop Suction,Remota, <br /> Rear of station,etc. Earth,etc. tubes.Remote Fills Sue.Manitolded Which tanks? Make if known <br /> 8. UNDERGROUND <br /> Depth <br /> water over the tank? <br /> WATER Depth to the Water table /u� / !J !?n ❑ Yes ® No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Telepnpn. <br /> ARRANGEMENTS 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, 771 Uw " 115115-117 la—if IT/ 1h 1111 <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS LNVINUIVItNTAE Iii <br /> Additional information pn any items above.Officials or others to be advised when testing is in progress or co" WWWME Xl=present <br /> during test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for }Tp l}1P <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: III ,,,,T <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> is <br /> Thte Is to certify that these tank systema were tested on the dates)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> Data s'r C , :(/ f_ , •(ee=e 7- r <br /> Iasunp Conuacm or Compo y. By: Signature <br /> Serial No.or Thermal Techniuens Address <br /> Sensor All. ._ . ,. .�:%fes%J ni/ -,J///i Uj <br />