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a <br /> 1 Data art for' Tank System Tig' )ess Test <br /> petro Tate <br /> PLEASE PRINT TANK TESTER <br /> a <br /> 1. OWNER Property ❑ 'f 40 W. V Stf,ck+W , (i/t <br /> Tank(s) Ela <br /> me Address Reo, senut. Telephone <br /> 5 Name Address Ae Dr.,entad.. Telephone <br /> 2. OPERATOR <br /> t Name Addrofs Teiepnone <br /> 3. REASON FOR +^' � i�I _ <br /> TEST <br /> r (Explain Fully) ,a <br /> FEBv tJ•" <br /> r 4. WHO REQUESTED 2 <br /> TEST AND WHEN Name Title Comdany Or Affiliation Dila <br /> Address ` /SERVI L FS Telephone <br /> 5. WHO IS PAYING <br /> Company,Agency Or Individual Person Authorizing Title Teia Doone <br /> FOR THIS TEST? <br /> Silting Address City State Zip <br /> I <br /> Attention oI: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier rade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED + I�(7c90 �te,Se- f ? e' <br /> o !&e00 See <br /> We V4 c 0U ? S f,-ej <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTADATA ELATION see- <br /> DATA (()W_K&TF_ I f/1 Z(F 2 <br /> DiaWHe- <br /> North Inside driveway. Concrete,Black Too. Site.Titetill make,Droo Suction,Remote. <br /> Rear of station,etc. Earth,etc. tubes,Remote Fills Site,Manifolded Which tanks? Make if known <br /> 8. UNDERGROUND ( Is the water over the tank ir <br /> phtpWATER Depth to the Water table Yes No <br /> Tanks to be filled hr. Date Arranged by <br /> r <br /> 9. FILL-UP Name Telephone <br /> ARRANGEMENTS Extra product to"top off"and run TSTT. How and who to provide 7 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 winiotC4%A_ �� be&± <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 pPIrO T _(1 <br /> 12. TEST RESULTS as detailed on attached test chaos with results as follows: ' <br /> Tank Identification Tight Leakage Indicated I Date Tested <br /> reSZI YE�L . lD <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 Asocialion Pamphle 329. �+ <br /> �6 <br /> S-6 L <br /> Date Hen Com aclof or Como B S uufa <br /> 2_�S— rn <br /> Serial No.OI Tnermal Technicians AOdre s <br /> '—so, <br /> m1 <br />