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Data Mart for Tank System Tight ress Test <br /> petro TA e_ <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER <br /> Tank(,) Name 71om/ R.o.o.mnn.. Tadashi...Name aanu map,....Iti T.NPhon• <br /> 2. OPERATOR <br /> N.me Adorers Telephone <br /> 3. REASON FOR <br /> TEST <br /> (E.Plaln Fully) -- <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Nam• Title Comoanv or Affiliation par. <br /> Address Tried.... <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Co...,.Affair,or lwl.wual Poison Amlrerlaln nn. rare~. <br /> Sitting Adores. City Sr.re SIa <br /> Atr.nden.11 Order No. Other Inatm.tiona <br /> Idy irwtion Capacity Brand/Suopli.r Girds Appros.Age Sbd/Fiberyless <br /> 6. TANK(S) INVOLVED l C� - C <br /> / <br /> Location Co.,, Fills Vents Siphons Pumps <br /> 7. INSTALLATION C14� / <br /> DATA <br /> In imbe arM1.w.r. l Conn..,Black Too. Sir.,nr.lm map.pwo G Sucaon.Remote. <br /> Reer OI sterlen.aK. fart era is 1,T.R•mole Fill. Sire.M...W.ad Wnicn Knse r Map d.hewn <br /> 8. UNDERGROUND - /� o� 1.tee W.1.1 dnr In.tank y <br /> WATER Depth to the Water table +%O/J � 1:1 vas 9AS <br /> Tanks to be filled hl. Data Arranged by <br /> 9. FILL-UP Name Abpn.ne <br /> ARRANGEMENTS E•tr•Product to"top off'and run TSTT. How..it no to ororids r Consider NO Lead. <br /> Terminal or other contact <br /> for notice or Inquiry <br /> C...... Name T.bpnon. <br /> 10. CONTRACTOR, _ <br /> MECHANICS, — <br /> any other contractor <br /> nyoNlid <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.officials or others to be advised when testing s in progress or on pirled.Visitors or observers present <br /> during test ate. <br /> Taste were mads on the above tank systems in accordance with test procedures prescribed for <br /> 12. TEST RESULTS P210T <br /> }ro I}P <br /> sa detailed on atlachsd test churls with result as follows: <br /> Tank Identification Tight Leakage Indicated Oat•Tested <br /> 13. CERTIFICATION This is to certify that these tank systems were tested on the dates)shown.Those Indicated as"Tight"meet the aitarla established by <br /> the National Fire protection Asoclatlon Pamphlet 329. <br /> 1'If <br /> Lawrence Tank Testing ,d <br /> pat• P.O. Box 407 <br /> 7J7 <br /> Sr. sib <br /> Sinal No dl Tn.rmer - r.=nn.,.m Downieville,California 95936 (916) 289-3109 <br /> Sante <br />