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111 Data Cor Tank ' <br /> PLEASE PRINT P T AUG 11 I9$7 <br /> zary rEsrFlr <br /> 1. OWNER Property [] pl�auth S ware _A t. _ 13_1 - ��� <br /> O Name ----- -- -_ �._ , _9 N. l�iad.dzsonYIC <br /> Tank(s) addresice`- __ }` 9520_2 <br /> (2�y5esentariv6 <br /> 6Tnlephune <br /> 2. OPERATOR r} l Reprsan,a,n,g <br /> B o Z t on T.I.phone <br /> 1 REASON FOR <br /> TEST -- ---- <br /> e__ <br /> aaliforrjiq SttLiaw___ --- <br /> Ifxplam Fully) - ------- ------- -._.. <br /> 4. WHO REOUESTED Del Bolton <br /> TEST AND WHEN Name - -..— 5/19/8 @ 2 :Copm <br /> Tine ��-__-_�-•�- <br /> Companll w Afhnatrun <br /> -----------_ �— ------ _ _ 'Dale <br /> Adutess ~T <br /> 5. WHO IS PAYING Pyn?Outh _+SC1Uare AAt `-- Talepp'nne _ <br /> FOR THIS TEST? Company,Agency or Individual • _ <br /> Person Authorizing - <br /> eilhnp <br /> Zip <br /> Order No.— -�" O,her Instructions <br /> Identify by D,reClwn Capacity �- - <br /> 6. TANK(S) INVOLVED 54181_001 Brand/Supplier Grade <br /> ��© Approx.Age Sleelr Fib.rglass <br /> Diesel 17yrs . Steel <br /> --- <br /> Location Cover <br /> 7. INSTALLATION north Fills vents <br /> Srphanes Pump> <br /> DATA side of Concerte 2 i 11_to None Eng. <br /> buildin <br /> Ninside Concrete, <br /> Pump <br /> Rudl. Slauun,etc Blackpp^ <br /> Size,Tilelnl trial,e,Drop <br /> Earltl,qlc, tunes.Rnm.t.Fills un.Rumuta, <br /> 8. UNDERGROUND Size.Merlltaltlpd wt,«n,�,,., S--run. <br /> I knuwn <br /> WATER Depth to the Water table __ Is the water over the tankr <br /> - --------- � Yes Ll No <br /> 9. FILL-UP Tanks to be filled _hr _ Date Arranged by <br /> ARRANGEMENTS Extra product to"top off'and run TSTT. How and who to provide t Consider NO Lead. Name —�— <br /> Telephone <br /> Terrnlnal or other contact <br /> for notice Of inquiry-- —— - -�— <br /> Company __ <br /> Name Ttt,ephona <br /> 10, CONTRACTOR, <br /> MEGHANICS, ---, -- - -- — -- ,_.� <br /> any ,he,contractor --- — --L_--- --- -- �'�— ---�-__-_�---`—�_. <br /> Involved <br /> 11. OTHER Vent will need to be extended approx. - <br /> INFORMATION . or 1 t a <br /> OR REMARKS -�-- --. --- <br /> dating es information on any Items above.Officials or otha�'is to be advised when testing Is ,n progress or Completed.Visnors or observers presents <br /> duan®test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for <br /> 12. TEST RESULTS as detailed On attached test charts with results as follows: �1 MRIII T1 le <br /> I Tank Idenbllcalion - <br /> Tight Leakage Indicated <br /> Passed ( _—�_ Date Tested — -- <br /> Failed - <br /> Cert, _ <br /> Copy --- - - --� <br /> Paid <br /> Charg Arrival Time 9:00 am <br /> Inv. 39 - 197 <br /> County - <br />