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Data Cort for Tank System Tigh ss Test <br /> petro TAP <br /> PLEASE PRINT TANK TESTER �,s <br /> 1. OWNER Property ❑ i'GD �/f' /ney, r �BOG I� 72:14/ C- ' <br /> Name Address Representative Telephone <br /> Tank(s) <br /> Name Address Representative Telephone <br /> 2. OPERATOR <br /> Name Address Teiephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Company or Affiliation Date <br /> Address Telephone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? Company.Agency or Individual Person Authorizing Title Telephone <br /> Billing R.ddress City State Zip <br /> r Attention of: Order No, Other Instructions <br /> • Identify by Directs n Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6.TTA�NK(S) INtr <br /> 4(7H <br /> y oaf of � .Goo C� u/✓G�ppr,DCISD ]' <br /> 3 WORTH J_mp <br /> — — — — _ — — Location Cover Fills Vents Sipho4es Pumps <br /> (--7 INSTALLATION OF ST����57- Co/yCRETE Q�mG�� <br /> DATA f'�ff,�T iU O l <br /> North inside driveway, Concrete.Black Top. Size,Titefill make.Drop Suction.Remote, <br /> Rear of station,etc. IEarth,etc. tubes.Remote Fills Size.Manifolded Which tanks 7 Make if known <br /> 8. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Water table 1:1 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, <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 F_±r0 T P_ <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: rANK rsF. <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> Sou�H o f t, v i 3 G <br /> OF O O 3 G /rl <br /> N Or o 1 2 H <br /> This 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 National Fire Protection Asociation Pamphlet 329. <br /> 1 1si EUcN R I/IV 15-A B4Cz <br /> Date Testing Contractor or Company. By: Signature <br /> ns-o/ exK Sr. N!r , Cf, r�4sS79 <br /> Serial No.of Thermal Technicians A4citess <br /> Sensor <br />