Laserfiche WebLink
Data %art for Tank System TigMess Test <br />petro Tit? <br />PLEASE PRINT TANK TESTER <br />1. <br />OWNER Property <br />f a <br />Tank(s) ElNome <br />Address <br />r <br />Representative Telephone <br />Nems Address <br />Reoresantative Telephone <br />2. <br />OPERATORrj <br />—4o <br />Nemo Address <br />Telephone <br />3. <br />REASON FOR <br />^' v L ^r //� c �• <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />a`e'r< r <br /><, ,i cv –72 <br />TEST AND WHEN <br />Name Ttlle Company or Anilietion Det. <br />7. VX Z_ r <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />C% 7' o f e ,../ <br />FOR THIS TEST? <br />Company, Agency or Individual Person Authorizing <br />Title Telephone <br />Billing Address City <br />sum zip <br />Attention of: Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />S/✓ <br />Capacity <br />Brand/Supplier <br />Grade <br />P Je C <br />Approx. Age <br />3 S <br />Steel/Fiberglass <br />o,. C <br />7. <br />INSTALLATION <br />OATA <br />Location <br />C d < <br />of t7r:ve <br />North inside driveway, <br />Rear of station, em. <br />Cover <br />C/Ir7A <br />Concrete. Black Too, <br />Earth, etc. <br />Fills <br />Size, Titefill make. Drop <br />tubes, Remote Fills <br />Vents <br />Size, Manifolded <br />Siphones <br />Which tanks i <br />Pumps <br />Suction, Remote, <br />Make if known <br />6. <br />UNDERGROUND <br />WATER <br />Depth to the Water table' C Co �j y ' <br />Is the water aver the tank? <br />❑ Yes ❑ No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Extra product to "top off' and run TSTT. How and who to provide? Consider NO Lead. <br />Neale Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company <br />Name Telephone <br />10. <br />CONTRACTOR, <br />�r <br /><< <br />MECHANICS, <br />/: r "� -r , <br />/C, /S - <br />any other contractor <br />involved <br />11. <br />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 />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for PPtrO TIte <br />as detailed on attached test charts with results as follows: � — <br />Tank Identification Tight Leakage Indicated Date Tested <br />S a, 7 —, 0 <br />�_ 2- d 7 <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 Asoclatlon Pamphlet 329. <br />?nn-PJDate ^t A SG <br />Tam4a <br />Signaturo / <br />r R r 7 G r l !O C ti < <br />Sensl No. of Thermal Technicians Adduss <br />Sensor <br />