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Data ClOrt for Tank System Tighte._.jss Test w'0 #Jri�.�3 <br /> PLEASE PRINT <br /> P �T!#�' station #s >U <br /> f <br /> 1. OWNER Property ©_ QZc C O• �9low <br /> Nem. Addra RepresenTsnk(s) �Lu/ <br /> TNeh � <br /> Nome 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 Nome Title Company or Arrinatlon <br /> o.a <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Agency or Individual Person Authorizing Tide <br /> Telephone <br /> Billing Address City State <br /> Zlp <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade <br /> Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED -r 0. Z c <br /> Location Cover Fills Vents Siphons Pumps <br /> 7. INSTALLATION tvFs 1'o F �o ,C,c,--C <br /> DATA 'I <br /> �jvr%rr✓Its /ISF/bra, 1 4 <br /> North Inside driveway, Concrete,Buck Top, Size.Titeflll make,Drop <br /> Aur of station.etc. Earth,etc. tuber Mmou FIIU Bue.Monllolded a Suction.Remote, <br /> Which tanks? Make If known <br /> 8. UNDERGROUND Is a..water over the tank 7 <br /> WATER Depth to the water table_ /z A4. 2 D ri 0 /->'�o .. <br /> El Yes ® No <br /> 9. FILL-UP Tanks to be filled hr. Date Arranged by <br /> ARRANGEMENTSNoTe Telephone <br /> Extra product to"top off"and run TSTT. Now and who to provide) Consider NO Lead. <br /> Terminal w other contact <br /> for notice or inquiry <br /> Company Nome 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 hems above.Officials or others to be advised when testing Is in progress or completed.Visitors or observers present <br /> during test etc. <br /> Teets were made on the above tank systems In accordance with test procedures proscribed forfp TAP12. TEST RESULTS as detailed on attached test charts with resuhs as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> 0 0 ,' ✓ (Z_ <br /> Hr <br /> Hr <br /> 13. CERTIFICATION <br /> This Is to C"fy that thea tank systems wen tested on the dates)shown.Tho"Indicated as"Tight"meet the criteria established by <br /> Me National Fire Protection Asociation Pamphlet 329. <br /> -Z/' / /S"7 ��m Wilkerson -� <br /> o.te — <br /> Tessin°ontractrof o any. nen e o n <br /> e y. ign.tur. <br /> Tree Reeves 2 Connie Drive-Sacramento - Ca. nc. <br /> s rIaIlJo. sw ermai TechniciansJeff Palmer°"'°r Contractor license Address 1 <br /> - <br /> #502377-C61 <br />