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1 r <br /> ` Gata Chart for Tank SVAM Tightness Test <br /> PLEASE PRINT <br /> �ar� k Ccr <br /> 1. OWNER Propertyl rp-�IOyI <br /> Tank(s) Name (( t` Address R.preshilove Telephone <br /> Name Address Representative Telephone <br /> 2. OPERATOR cr Y 0 ;iZe dMT $� <br /> Name Address <br /> Telephone <br /> 3. REASON FOR ee <br /> TEST <br /> (Explain Fully) t <br /> 4. WHO REQUESTED kAr, crin li, ca r <br /> TEST AND WHEN Na Ti' c mpenyorAnlllatwi <br /> �fi� � Man ani-�F. AvR C'c�,�ti+ G_�� A Data <br /> Address—� .Telephone <br /> Identity by Direction Capacity Sra^nnd,Suppller Grade Approx.Aga Steel/Flberglase <br /> 5. TANK INVOLVED @ b00 f-1ef0 k <br /> - O er re-utnL o s'1- <br /> Use addhlooal lines w.. <br /> for manlfolded tanks T o co <br /> if <br /> LocationCops ve�. Fill, Veno Siphon., Pumps <br /> It <br /> 6. INSTALLATION 6LT at <br /> DATA a Q Q �t <br /> 11 (y covlcreFe '4- �. N01A1Z_ .oh <br /> AOd�sldf7drlveway, Concrete,Black Top, site,Tllellll make,Drop Suction,Remote, <br /> Rear of station,etc Earth,etc lubes,Remote Fills Size,%lanilolded Which Lean? Mese If known <br /> 7. UNDERGROUND p� y lethewetero erylh�nk? <br /> WATER Depth m the W.I .table a1� ❑res IJ No <br /> 8. FILL-UP Tann tobefel.d(nmitr. !' —Date Arranged by 11FTS <br /> Nmm� Telephone <br /> ARRANGEMENTS Extra product to'Yap our end vin Lank Leets Now and who to provide? consider NO Lead. <br /> h C'd rZ <br /> Terminal or other contact <br /> for notice or Ingulry <br /> Company Nepro Telephone <br /> M�T5 -- -- <br /> 9. CONTRACTOR, — <br /> MECHANICS, _ I <br /> any other convector II <br /> Involved <br /> I <br /> 10. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional Informallon on any Items above.Officials or others to be advised when testing b In progress or com <br /> Testa were made on the above lank systems In accordance with test procedures prescribed for <br /> 11. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification I I Tight Leek a Dela Tested <br /> s 1, e _;L <br /> fill- <br /> Ir ., r 1- <br /> 3_ > e21 <br /> 12. SENSOR 13.This Is to certify that these tank systema warns tested on the detep)shown.Those Indicated as-Tight"meet the criteria established by the <br /> CERTIFICATION National Fire Protection Association Pamphlet 32& <br /> Techniciansf t <br /> to �j yls yi M r F;T, S <br /> I b 4�� �1.5��� r� \TM11np Conlrector or Company. By: Signature <br /> Serial Ne.Of Thermal certification zGlz— L ] o b4" Si" 21� ���' __ CA Sensor `V VIA J"1 �'!� l A <br /> �'3 rk b� Addrr,e 92"715 <br /> 2 <br /> Certification e <br /> PNiie27 <br />