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Data Cft for Tank System Tight ;s Test �? <br /> pPfro Tote ... � <br /> PLEASE POINT TANK TESTER /19 �' <br /> 1. OWNER Property p <br /> ( © Name jy'r ac TJaa _ �. Representative Telephone <br /> Tank s) dX <br /> Name Address Representative Tatephone <br /> 2. OPERATOR Name Address Telephone <br /> 3. REASON FOR &/a < <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REOUESTED <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TESTI Company,Agency or Individual Parson Authorities T tle Telephone <br /> Billing Address CIN State zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED +sJ Z <br /> /472 -Y - <br /> Location Cover Fills Vents Siphons Pumps <br /> 7. INSTALLATION <br /> DATA <br /> Nonh inside driveway. Concrete.Black Top, Size.Titefill make.Drop Suction,Remote. <br /> Rear of station,etc. Earth,etc. tubas,Remote Fill, Size.Manifolded Which tanks? Make if known <br /> 6. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table O Yes ® No e <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top oft"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, �- <br /> any other contractor <br /> involved <br /> 11. OTHER ✓;'e'n / .. C'�,, o <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 plis—tr0 t1P <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: �T <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> Yrs a. <br /> This Is to certify that these tank systems were tested on the date(s)shown.Those Indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> Date Testing Contractor or company. By: signii <br /> Serial Na.of Thermal Technicians Address <br /> Sensor <br />