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Data Chart for Tank System Tightness Test oma+ <br /> Y 9 <br /> petro TAC-1 <br /> TANK TESTER <br /> 1. OWNER property R� SAnll'-rAQ✓ CTT%/ ; i, 0.9hfi1 362 f Z <br /> N Name 333 --:—*44; <br /> —*44; Telephone <br /> press` s �� <br /> Tankta) L7 <br /> Name Address Telephone <br /> 2. OPERATOR SAmE� <br /> Name Aptness Telephone <br /> 3. REASON FOR TEST V �� <br /> (Explain Fully) <br /> 4. WHO REQUESTED FIaQQ� CQU <br /> (ESI AND WHEN Name TitW Oompany or Affiliation Date <br /> AA Address cI 8c Telephone <br /> 5. WHO IS PAYING SANiTAR✓ C iT�/ <br /> 1TH <br /> FOR THIS TEST? Company,Agency or newidual Person Autnonzinp L Tp1gl-`r tLo Telephone <br /> Billing Address City State zip <br /> Attention of: Order No. Other Instructions <br /> 6. TANK(S) INVOLVED Identify by Direction Capacity Grade Approx.Age SfeellFiberglass <br /> Sot�[N TRNk OOD +E2�iE5E1 ? IAAl Ludo/J <br /> 7. INSTALLATION Location Cover Fills Vents Siphons Pumps <br /> DATA 01/6: VARD Ccwe?E7F 36 y w.rc �CTio <br /> North inside drivCway, Concrete.Black Top. Size.Tifefdl make.Drop Sucten,Remote. <br /> Rear of station.etc. Earth.etc. luoss.Remote Fills Size,Manifolded Which larks' Make it sewn <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to water table if known ElLJ P/No <br /> No <br /> 9. FILL-UP <br /> ARRANGEMENTS ranks to be fined (2 10 Date Arranged byyyN4 m Ui� a?/C <br /> Name Telephone <br /> Hour <br /> 10. TECHNICIANS <br /> Aeo <br /> 11. OTHER -nm,�O sdoca-T A DRGz .CoC 00irw �sT aYVG?fie,! <br /> INFORMATION '— 071 A/%w! <br /> OR REMARK6x4lictais IQ /_4 <br /> S 4DV4%W � W vE m J^lrymy., iToQ Q —mo f o&< LV,_) moi[ <br /> Tri <br /> Additional information on any Items above.Officials or others to pe advised when testing is In progress or completed.Visitors or observers present <br /> during test,etc. <br /> 12. TEST RESULTS Tests were made on the above tank systems in accordance with test procedures prescribed for PPtrO Title <br /> as details on attached test charts with results as follows: w+x Ilu <br /> Tank Identification Tight Within Tolerance Out of Tolerance Date Tested <br /> gm-V-n+ nta -UP G. P.-l. Iz-►o <br /> 13, CERTIFICATION This Is to certify that these tank systems were tested on the date(it)shown.Those indicated as"Tight"meet the criteria established by the National Fire <br /> Protactlon Association Pamphlet 329. <br /> (Z-1 D Name of <br /> person certifying <br /> Date , A/TI <br /> ra r or C an : - a <br /> mot 2r A� Testing Y. BySlure <br /> 4(d81314 mb _ ?z$I nl rr,A <br /> Sepal No.of Thermal Sensor Certifcation Number Address 95.24/1 <br />