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Data Chart for Tank System Tightness Test <br /> �,/. pPfrO TitP <br /> PLEASE PRINT s� /���� TAN <br /> 1. OWNER Property <br /> T� NameAddress <br /> Tank(s) / �� ReDr.s.nta Uv.'� T•LdnOn. <br /> Name Address R.or...Mail-C ia•oho n• <br /> 2. OPERATOR <br /> Name Address Tdaohon. <br /> 3. REASON FOR 7y 4f1 <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Comoany or Affiliation Date <br /> AdOress <br /> T•i.ohon. <br /> 5. WHO IS PAYING s N� <br /> FOR THIS TEST? Com Oany.Ageric Or Individual Person Authorizing Title T.laohona <br /> Billing Address City State jlp <br /> Attanllon or: Order No. Olhal Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fibergil ss <br /> 6. TANK(S) INVOLVED <br /> /o ,Z 47W L <br /> A AfL r/t 2 $�f 4A 0 /v E <br /> ASTEL <br /> Location A/.Jl Cover 'Pills Vents Siphones Pumps <br /> 7. INSTALLATION -/ _ <br /> DATA d]allJ �O�iGieK T� *..;" s► 'rO�CI��1 Y1� <br /> North Inside d,iAay, Concrete.Black Too. Size.Titdill make.0100 Suction.Remote, <br /> Rest of station,ate. Earth,etc. lubes.Remote Fills Size,Manifolded Which Tanks r Make d known <br /> 8. UNDERGROUND Is the-ajar over the tank <br /> WATER Depth to the Water table yes No <br /> 9. FILL-UP <br /> Tanks to be filled 9e hr. 7�p �u Arranged by ��J y V ''' <br /> ARRANGEMENTS Extra product t0"top off"and run TSTT. How and who t0 provide 1 Consider NO lead. Name Taleohona <br /> Termitic or oche Contact />p O t 7 k <br /> for notice or inquiry_ /C7 iL. IG CJ <br /> Company Name <br /> 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 /> Testa were made on the above tank Systems In accordance with test procedures prescribed forPp}r0 TIle <br /> 12. TEST RESULTS as detalled on attached test charts with results as follows: ti X11— <br /> Tank Identification Tight Leakage Indicated <br /> Date Tested <br /> f*I ifU"l, 00; <br /> S GD 41 - - <br /> 0 <br /> 13. 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 /> CERTIFICATION <br /> the National Fire Protection Asoeistlon Pamphlet 329. <br /> Date Lawrence Tank Testing <br /> P.O. Box 407 <br /> 4%g�fur. <br /> $Soy"d df it Downieville,California 95936 <br /> Senea ecnnacrant <br /> (916) 289-3109 <br />