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Dat#hart for Tank System Ti jtness Test <br /> ?t •petro Tde <br /> SAiJ J oAc, <br /> P:CASE PRINT TANK TESTER <br /> i1. OWNER Property <br /> / ❑ C0 IIJ � Z -S - oz 7r <br /> ❑ ,` n <br /> Tank(s) Atltlnss Representative TNeDho" <br /> ( �C n CO <br /> l <br /> Name ` Address Reoresentabve e•chone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> I 3. REASON FOR 0 t <br /> TEST <br /> (Explain Fully) <br /> I <br /> 1 4. WHO REQUESTED Z� <br /> TEST AND WHEN Name Title Company or Affikation Date <br /> Address Telephone <br /> 3. WHO IS PAYING o bun <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/Supplier rade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED �O �T�Q / / <br /> aeon Cover / Fills Vents Siphones P mps <br /> 7. INSTALLATION ��Z �� ��az(�j`� I Al <br /> DATA <br /> North inside driveway, Concrete.Black Top, Size,Titefill make.Drop Suction,Remote, <br /> Rear of station.etc. Earth,etc. I tubes,Remote Fills Size.Manifoltled Which tanks? Make it known <br /> 8. UNDERGROUND Is the water over the tank 7 <br /> WATER Depth to the Water table`— / ` ' ❑ Yes g 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 /> Compaq Name Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> OR REMARKS <br /> Add-tional information on any items above.CMcials or others to be advised when testing is in progress or completed.Visitors or observers present <br /> durin,i test etc. <br /> Tests were made on the above tank systems in accordance with test procedures prescribed for pftf0 r±b / <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: <br /> Tank Identification Tighj Leakage Indicated Date Tested <br /> i — <br /> r Of <br /> This Is to ce"that tf�ss tank systema vers tested on f+v s TIgosAth. teria.ataaishad by <br /> 13. CERTIFICATI the Nat n Ion is PamphW 329. S 1 <br /> Dots Tearing Contractor or Company. By: Srg nature <br /> _ 6` <br /> Beata No.ot The nai aa:nnrcrerta Adorers <br /> Sensor <br />