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Data dart for Tank System Tigo., ess Test <br /> Me-tro he <br /> �T .ATTACHMENT D ' <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ KA q Q i '60'r C- ! o y L Q-D i <br /> ❑ Name Address Representative Telephone <br /> Tank(s) <br /> Name Address Representative Telephone <br /> 1. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company or Affiliation nate <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> Company,Agency or Individual Person Authorizing Tile Telephone <br /> FOR THIS TEST? <br /> Billing Address City State Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steei/Fiberglass <br /> 6. TANK(S) INVOLVED EAST I0600 EZle-INS SYE:C-L <br /> CU JT61Z 10000 <br /> 'r <br /> 1/V�ST p0O0 <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION LIVES T 6,4 A'/6 go-otic. 1 _ 4•to � _ 3t' TuaisIru 5 <br /> DATA 3L�P6• - Zrr <br /> North inside driveway, Concrete,Black Top. Size,Titefill make,Drop Suction,Remote, <br /> 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 ❑ 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, j A g , <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 for Petro nthe <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: IAN"'ESTER <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> ST,rt�u if iW-s — 0 8 AIL 30 ja <br /> G>;NT�2 — i1J L.k/4b -3- <br /> 44m 19 <br /> fE s44m19a uNL GPL-Z life 3a jai-y 5' <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 so <br /> Adellion Pamphlet 329. <br /> Date !� r ZA4,�J'S./ <br /> 1 �. <br /> ..q Testing Contractor or Company. By: Signature <br /> Serial No.of Thermal Technicians Address 1: <br /> Sensor <br />