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Data d art-for Tank System Tightftiess Test <br /> PPt�rO Tiff <br /> PLEASE PRINT <br /> 1. OWNER ProgenyN 'O-- <br /> H•m•y Aaa»u Ray»NnMYy TV•ah.n• <br /> Tank(.( <br /> Na». Adau. A.exannMtlr• TNpMn• <br /> 2. OPERATOR T .0a r <br /> WM Aderete TNesbne <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully( <br /> 4. WHO REQUESTED T �- <br /> TEST AND WHEN "'"" TW. canister.1 AUYlauon <br /> Data <br /> AUama <br /> iM•MOM <br /> 5. WHO IS PAYING91 L <br /> FOR THIS TEST? Cames.E"endr a lMlrldesl Pmon Autharltl^e, Title Taeahone <br /> 111111"Aderte. City Suits <br /> All•nbn el: Did.,Na. Dlher Innructiens <br /> Idmtih by Direction Capacity BOM/SNPpliet Grad. Approx.Age, Steel/Fiburgla <br /> 6. TANK(S) INVOLVED — ; / �%. <br /> `T 7 UNLEAO <br /> C ! /9 "'K'7 UL/a <br /> Location Cove Fill, vt giphonee Puntge <br /> 7. INSTALLATION <br /> DATA <br /> Nonh M.Id•arw•rar. C.I.I.,@lace red. 51»."cant Drop @ua11M.beret@ <br /> are.sr @rile"alt. Euq ac. luaw.Rome»FYb @lea.Menelaus" wMN Ynb I Mw.Y enerm <br /> 8. UNDERGROUND I.the wets,over%he,to" <br /> WATER Depth be WA waw was, yes 5�Ne <br /> 9. FILL-UP Tank'to be filled hr. Dau Arranged by <br /> Na»e Talesha» <br /> ARRANGEMENTS -us Padua be air we tun TiTT. Now end he Consider NO lead. ,r <br /> L <br /> Taminal or other contact <br /> Fair notice,or inquiet - <br /> t'e'le'Rr" N.. Tele,aa.we <br /> 10. CONTRACTOR, ' <br /> MECHANICS, <br /> any other Comneta <br /> involv.d <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional inlormalipn a.arty i»m.•have.ollici•ir or otMq to be adl..d whm I•epng iF In pipettes W Completed.Vi@ibra W go".,$Paean. <br /> during test etc. <br /> Teats wan made on the,above tank systams in accordance with teat procedures proscribed LorI}! <br /> 11. TEST RESULTS as detailed an•"ached test Chane with results as lonowa .1}1remmT <br /> Tank We,ntitkatbn Tight Lubec indiubd Data Tested <br /> a <br /> - 02 Lj —S- <br /> 13. CERTIFICATIONThla I.to certify that Me..tank systema were bsbul on the date(s)shown.Those Indlcatad 00"Tight'hest the Cal wa,Otab(ahed by <br /> NitNational Fire,protection AUia"pn pamphlet 33e, <br /> Lawrence Tank Testing, <br /> P.O. Box 407 a� are ` <br /> er No.atrh.,mr <br /> ser <br /> Senor ahnicynr Downieville,California 95936 (916) 2891.3109 <br />