Laserfiche WebLink
Data CAI for Tank System TighAss Test <br /> petro T1tP <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ A�' - a�$� ;AQ N.Ulc,1;rc&vsr! <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 <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN his Title Company of Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company,Agency or Individual Person Authorizing Title Telephone <br /> Billing Address City State Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED �/?Sr 10 . O0� f c(a RE6kUYR Lr/lD /E h"5 (J- <br /> w�sro 0 o PR�c S14PEi? u <br /> wf4 rASf Location Cover Fills Vents Siphones Pumps <br /> 7. ;INSTALLATJi�J1 I -iry �T T O�G�► j1 ii 2 C R�irr T� <br /> DATA o„ G F_ 5 A sow .� ✓ <br /> North inside driveway, Concrete,Black Top, Size,Titefill make,Drop Suction,Remote, <br /> I Rear of station,etc. Earth,etc. tubes,Remote Fills Size,Manifolded Which tanks? Make if known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table LJ Yes 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.Officials 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 forPetro jlt( <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: "" Tl'l` <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> E,q5r RE6 LEAQ TSG-NT ,OC H ili- <br /> w uPER <br /> This Is to certify that these tank systems were tested on the date(s)shown.Those Indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asoclatlon Pamphlet 329. <br /> Date Testing Contractor or Company. By. Signature <br /> 25G/ OpK 5i &,. Pw, 6,n - <br /> Serial No of Thermal Technicians Address <br /> Sensor <br />