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Data iohart for Tank System Tightness Test <br /> pp=rite <br /> PLEASE PRINT TANK TESTER <br /> 1. OWNER Property 7 -( s rC r' rSI Air N 6 N T /7!-*/I\;1- 4 t- <br /> Tank(s) Name - Address. Representative Telephone <br /> Name Address Representative Teleohpne <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST _ y�, I <br /> (Explain Fully) <br /> 4. WHO REQUESTED 0 t4 V l= L i= W I 5 <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Tnleohone <br /> 5. WHO IS PAYINGLNN CC 2_1J <br /> v <br /> FOR THIS TEST? Comp . ancy or In ivr SL / �e Aypygi;lnp ill A ��`I S n Telephone <br /> Billing Address L ) �'I�.rcity 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 <br /> 1.71 ,o D CLC - <br /> OF V L <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION <br /> DATA o F �'v rZj:� <br /> (( Z r( 7,10 K(I I E t-( <br /> North inside driveway. Concrete.Black Top. Size.Titeflll make.Oroo 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 // U Yes No <br /> Tanks to be filled LL�hr. 3 Z^ 6' b Date Arranged by IC A T-H - <br /> 9. FILL-UP Nams Telephone <br /> ARRANGEMENTS Extra product to"top off'and run TSTT. How and who to provide? Consider NO Lead. <br /> Terminal or other contact ^ j n "� <br /> for notice or inquiryf5 L N 1 C t(T-�^) <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 an 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 <br /> 12. TEST RESULTS as detailed on attached test charts with results as touows: R.d. 5 ift, <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> V O 2Sr. <br /> ' - Z- zE - y4 <br /> C <br /> s <br /> Thls is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight'meet the criteria established by <br /> 13. CERTIFICATION the Nations Fire Protection Asocladon Pamphlet 329. <br /> z--(L� --r--�- R,3�r�, �F. DL . 1<d Lawrence Tank Testing - <br /> Data P.O. Box 407 By: — Signature <br /> 1 L1-c Z <br /> Serial NOe,(- 5'i s�Or Thermal Technicians Downieville,California 95936 (916) 289-3109 <br /> . <br /> Sensor <br />