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• Data Chu_ _ for.Tank System Tightne, Test <br /> pe <br /> jro TitP <br /> PLEASE PRINT TANK TESTER OM <br /> 1. OWNER Property ❑ C o ,j P\0 k <br /> Tank( <br /> s C..l�) )C❑ -i�//� Address Representative -fT61 h n C <br /> Name Address Representative one <br /> 2. OPERATOR Z / <br /> Name Address Telephone <br /> 3. REASON FOR 4 <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 / /V 45 <br /> FOR THIS TEST? Company,Agency or Individual Person Authorizing Title Telephone <br /> Billing Address City State Zip <br /> Attention of: Order No. Other instructions <br /> Identify by Direction Capacity Brand/Srapplier rade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED AO 72�X/7 / / <br /> anon Cover Fills Vents Siphones P ps <br /> 7. INSTALLATION ri4�Z <br /> DATA <br /> North inside driveway, Concrete,Black Top, Size.Titefillmake.Drop Suction,Remote. <br /> Rear of station,etc. Earth,etc. tubes.Remote Fills Size,Manifolded Which tanks 7 Make if known <br /> 8. UNDERGROUND / Is the water over the tank 7 <br /> WATER Depth to the Water table ! ❑ Yes No <br /> Tanks to be filled hr. Date Avranged by i <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 othersto 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 PP r TitP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tighj Leakage Indicated Date Tested <br /> INC. OF S <br /> This is to certify,that ss tank systems were tested on 411 s sht ^ yt Tigl� the t established by <br /> 13. CERTIFICATI the Nation re ProIct <br /> ion Asoqa Pamphlet 329. S <br /> DateQQ Testing Contractor or Company. By: Signature <br /> Serial No.of Thermal Technicians Address <br /> Sense <br />