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f � <br /> Data dart for Tank Sy tem Ti 1k,-Aess Test <br /> _ petroits <br /> PLEASE PAfNT TANK TES ER ATTACHMENT D <br /> 1.. OWNER Property ❑ K11�J O f L gQO /_— <br /> Name _r It �T <br /> Tank(s) ❑ Adtlress Representative <br /> Telephone • <br /> Name Adtlreu <br /> Representailve Telephone <br /> 2. OPERATOR <br /> Name Address <br /> 3. REASON FOR Telephone <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title <br /> Company or Affillatlon Data <br /> 1 <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company,Agency ar Individual Parson Aut prizing <br /> Title Telephone <br /> Billing Atldrass <br /> City State <br /> Zip <br /> Attention o!: Ord r No. Other fnstruc[ipns <br /> Identify by Direction Capacity Brand/Supplier Grade s <br /> Approx.Age Stoet/Fiberglass <br /> 6. TANK(S) INVOLVED EAtsr 10600 ZtC.1AJS SY�L <br /> C�A.1 r I 1 000 C) <br /> lel sr 00 o 11. <br /> , <br /> H <br /> I <br /> Location Cover Fills Vents Siphons Pumps <br /> 7, INSTALLATION WES`r B� A/C 10,OAic 1 µki J _ 3" a <br /> DATA R`31r 'G. 1 Z,rTu23►n>�S <br /> I <br /> North inside driveway. Concrete,BlaCk Top Si Tile <br /> ellopRear of station,etc. Earth,etc. tubesRem t Fills .I <br /> Suction,Remote. <br /> Size,Mandolded Which tanks? Make it known I <br /> 8. UNDERGROUND Is the water over the tank 7 <br /> WATER Depth to the Water table t <br /> ❑ Yes ❑ No <br /> I <br /> 9. FILL-UP Tanks to be filled hr. Date Arranged by <br /> ARRANGEMENTSName Telephone <br /> Extra product to"top off"and run TSTT. How and who to rovide? Consider NO Lead. � <br /> Terminal or other contact <br /> for notice or inquiry <br /> Company <br /> Name Telephone � <br /> 10. CONTRACTOR, A r— <br /> MECHANICS, <br /> any other contractor ' <br /> involved <br /> 4 <br /> 11. OTHER ji <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Officials ur others tc 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 fortr0 ttP <br /> 12. TEST RESULTS as detailed on attached test charts withresults as follows: 04— <br /> Tank Identification Tight Leakage Indicated <br /> Q Date Tested <br /> •tier? RL 3C, 4 <br /> - Gti�T�2 ._ �l��b ags , 4 l l� rt•c.. uG y <br /> 6I}57-- Su2 44 WL IIS Yd Jury . ' <br /> This Is to certify that these tank systems were tested on thi P date(a)shown.Those Indicated as"Tight"most the criteria esta6ilshed toyr <br /> 13. CERTIFICATION the National Fire Protectio�nr%Asoclation Pamphlet 328. <br /> Data <br /> Testing Contractor or Company. By: Signature - <br /> 1 R <br /> Serial Pio.of rnennaf Technicians - <br /> Senses - - _ _ Address - <br />