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AINLAY TANK `TEGRITY TESTER Tk'FIELD TEST <br />1 NAME ADDRESS PMW/SERVICES <br />TANK _ V 't c T Fc>�I�ce ud G - JI r , AA <br />OPERATOR aQ c <br />2 IDENTIFICATION CAPACITY—GALS. MANUFACTURER STEEL/FIBRGLS. AGE—YRS. <br />I P_+z <br />TANKS TO <br />BE TESTED / / <br />3 WATER <br />DISTANCE FROM GRADE TO WATER INS. <br />TABLE <br />4 TANK WILL BE FILLED ZperL (TIME) ON 65a/p7 <br />TANK EXTRA 5 GALS PRODUCT AVAILABLE FROM <br />FILL -UP FILL UP TO BE ARRANGED BY MR. Ul ,— Eer In PHONE( ► $ $- <br />CONTACT AT STORAGE TERMINAL IS MR. PHONE( <br />5 NAME ADDRESS PHONE <br />OUTSIDE <br />CONTRACTORS <br />6 NAME AUTHORITY PHONE <br />OFFICIALS <br />TO BE <br />CONTACTED <br />7 77L) )OC <br />SPECIAL �: � o �r�ti � �r �� a-t'j c- !d, <br />NOTES OR <br />PRECAUTIONS <br />8 ALL TESTS WERE PERFORMED IN ACCORDANCE WITH PROCEDURES DESCRIBED IN SOILTEST'S <br />INSTRUCTION BOOK. CRITERIA FOR TIGHTNESS IS ESTABLISHED BY NATIONAL FIRE PROTECTION <br />ASSOCIATION BULLETIN, N.F.P.A. 329. <br />TEST <br />RESULTS <br />TANK )DENT TANK IS <br />TIGHT <br />TANK IS LEAK RATE <br />NOT TIGHT G. P. H. <br />TEST DATE <br />o E <br />/o 7 Z,? <br />,I <br />/d <br />9 THIS CERTIFIES THAT THE TANKS DESCRIBED WERE TESTED BY THE UNDERSIGNED AND THAT THE STATED <br />RESULTS REPRESENT THE TRUE STATE OF THE TANKS ON THIS DATE TO THE BEST OF MY KNOWLEDGE. <br />CERTIFICATE NO. <br />CERTIFICATION SIGNED ISSUE DATE 1,22 2-7 <br />FOR (TEST COMPA i <br />ADDRESS el C) 0cl <br />�^ <br />TATE ZIP <br />