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Data CAI for Tank System Tightl*ss Test <br /> Pp-TOP <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ # $ %�y 1:� N. USC Fri Z S��C TC/1/ GA <br /> ❑Tank(s) Name Address Representative Telephone <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST r/ <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company of Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> Company.Agency or Individual Person Authorizing Title Telephone <br /> FOR THIS TESTI <br /> Billing Address City State Zip <br /> Attention of Older No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED ERsr 14R6a LMO /o JIX <br /> w�sr cc�� rip,Rcc su�Fa°y l� Y�i's <br /> vE4 eAs> Location Cover Fills Vents Siphones Pumps <br /> 7. :INSTALLAT� p N s Son O�G/✓ �� /r�C ni /=/ 7G <br /> DATA o„ <br /> f >41 North inside driveway, Concrete,Black Top. Size.Titefill makeFills,Drop Suction,Remote. <br /> 1 Rear of station,etc Earth,etc. tubes.Remote Size,Mandoldsd Which links Make d known <br /> 8. UNDERGROUND Is the water over the tank <br /> WATER Depth to the Water table 'El Yes 5d No <br /> Tanks to be filled hr Date Arranged by <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to''top off"and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company Name Telephone <br /> 10. CONTRACTOR, - <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officals or others to be advised when testing is in progress or completed.Visitors or observers present <br /> during test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for PptrO T e <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification I Tight Leakage Indicated Date Tested <br /> ENSr OC-57 <br /> This is to certify,that these tank systems were tested on the date(&)shown.Those indicated as"Tight"most the criteria established by <br /> 13. CERTIFICATION the National Fin Protection Asociation Pamphlet 329. <br /> ;Lt 5-/ 1/3CA? R !/SRL-A aecK&R r/VP <br /> Date Testing Contractor or Company- By. Signature <br /> SSC/ OP ISS% /L-/JPI,' 61"? I 5I -- <br /> Senal No of Thermal Technicians Address <br /> Sensor <br />