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Data CV1 for Tank System Tighj#ss Test <br /> petro Tate <br /> PLEASE PRINT ANk TESTER <br /> 1. OWNER Property ❑ kf/ �rj'fs �J L'• �/ of V,,, i.. ( , P <br /> Wine Address ReDie"ntaFiva T,bphonf <br /> Tank(s) Fi <br /> Norco Address reqs Representative 7 aleph on e <br /> 2. OPERATOR �'5c a-c� ) `o /2'�Ctr <br /> Nar <br /> mr Address Te4Dhone <br /> 3. REASON FOR 2 n •J PA 4-1 h <br /> TEST <br /> (Explain Fully) f <br /> 4. WHO REQUESTED <br /> / company or Affiliation D <br /> TEST AND WHEN rifle ate - <br /> m G /�� i' -fit v c' f <br /> Address �' I y C-) �� ? -/� t`�L <br /> Telephone <br /> 5. WHO IS PAYING l' c'Z \� >Gl /_/n)-1- <br /> Compare en y or_Indivi us' Person utnor nq� Title Telephone <br /> FOR THIS TEST? <br /> �r' e - , s"� C <br /> BilOng Address City State Zip <br /> Attention of: Order No. Other instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steell Fiberglass <br /> 6. TANK(S) INVOLVED 2k I <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION p-C- ('to ir'a *-,- " <br /> SGtCt0L', <br /> DATA ac ��/ _` a. <br /> North inside driveway. Concrete.Black Top. Size,Titefill make,Drop Suction.Remott. <br /> Rear of station,etc Eanh.etc. tubes.Remote Fills Size.Manitolded Which tanks 7 Make it known <br /> 8. UNDERGROUND �� � +y Is the water over the tank 7 <br /> WATER Depth to the Water table �' '� �'' ' Ji � Yes No <br /> Tanks to be filled hr. Date Arranged by Nome Telepno,e <br /> 9. FILL-UP <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 re!epnone <br /> Company Name <br /> 10. CONTRACTOR, <br /> MECHANICS, g. <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Additional information on any items above.Ofhtaals or others to be advuedMWlt�tr�tt%Q-£,pitL re r ted Visitors or observers pesent <br /> during test etc. <br /> Tests were made on the above tank systems In accordance with toot procedures prescribed for WTttR[TILT <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tight Leakage Indicated Date Tested — <br /> This Is to eertity that these tank systems were tooted on the dates)shown Those Indicated p'"Tight"Itlset*A erl►erls established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. 0 <br /> —LJ �,' ✓�I — EP:Vi„vi::. L :£(„i,__C:,1 £il ____��i J► r <br /> Dna ' -Ting�o�inctor or ornWny stu.e <br /> 4 G P.IO. B�O,tX�2�007g6,, STOC!;TO!!, CA 201 <br /> Te[nr;R�: (2209) <br /> 11140,1111111140,11111Nu l or Thermal <br /> senwx <br />