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_ Data dOart for Tank System Tigl6ess Test <br /> Tlie <br /> PLEASE PRINT TANK TESTER <br /> F <br /> 1. OWNER Property <br /> Tank(s) ® Name Address Representative Telephone <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3, REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company or Affiliation Dafe <br /> Address Telephone <br /> 5. WHO IS PAYINGFOR THIS TEST? Company,Agency or Individual Person Authorizing Tile Telephone <br /> Billing Address City 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 S 1- 7 ��F� 77 <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION �'f <br /> DATA <br /> Node driveway, Concrete,?deck Top, Size,Titefill make,Drop Suction,Remote, <br /> Rear of station,etc. Earth,etc. tubes,Remote Fills Size,Manitolded Which tanks? Make if known <br /> 8. UNDERGROUND 'ell t/ Is the water over the tank? <br /> WATER Depth to the Water table G• ❑ Yes No <br /> Tanks to be filled hr. Date Arranged by <br /> 9. FILL-UP Name Telephone <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 Tvlephons <br /> 10. CONTRACTOR, <br /> MECHANICS, ��- f' <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 petro, to <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: TAW ng <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> This is to certity 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 /> y'r <br /> Date' <br /> Testing Contractor or Company. By: Signature <br /> Serial No,of Thermal Technicians Address <br /> Sensor , <br />