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rTWE/JVIRONMENTAL <br /> rLABORATORIES <br /> INC. <br /> PLEASE PRINT Data Chart for Tank System Tightness Test <br /> 1. OWNER Property _51— <br /> Name Address Representatrvn Telephone <br /> Tank(s) <br /> Nemo Address H nwnsu nta n v n T sleDhone <br /> 2. OPERATORName <br /> Address Address Telephone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) ---------- - ------ - <br /> 4. WHO REQUESTED <br /> Tine Company or Affiliation <br /> TEST AND WHEN Name Date <br /> 19-72 Al. Pi,t .Z 7)R. S 7't�k Tcvv C� -- .2,79- ?4/-/- S/o/6 <br /> Address t etepnone <br /> 5. WHO IS PAYING �r�r K>•✓-_�n�i �/ -��,, „[ ��s>. 4&,/yr�!;tu;�L�1r' sos7- yYY___f�'1� <br /> Company,Agency or Individual Person Authorizing Tine Telephone <br /> FOR THIS TEST? <br /> Billing Address City Stale Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> A/ Svc, r4 /1z Ori3 're c <br /> 6. TANK(S) INVOLVED _rs���_ a .;,r _- - - __-- S 7- - <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION "',SO 6✓dt �/r'/ T -1 `'/” <br /> �F ter/a v •� <br /> DATA y'W` <br /> North inside driveway. Concrete.Black Top, Size,Titefill make,Drop I Suction,Remote, <br /> Rear of stauif <br /> on,etc. Earth,etc. tubes,Remote Fills Size,Manolded Which tanks Make d known <br /> 8. UNDERGROUND Is the water over the tank <br /> WATER Depth to the Water tablef _ _- Yes L� No <br /> Tanks to be filled hr._ Date Arranged by __- <br /> 9. FILL-UP Name Telepnone <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 '14 Trzic�.r. 1Z,-Ag�� <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 lest procedures prescribed for NP-to-TA!" <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: A, lull[ <br /> Tank Identification Tight Leakage Indicated Dale Tested <br /> c F fill _— - -- - --- <br /> This is to certify that these tank systems were tested on the date(s)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> �-` Date ce H7 IL•/ .,—__-- lostrng Contractor or CY,rn?,jr y <br /> / 30-7 ENVIRONMENTAL LABORATORIES, INC. y—i'Signature <br /> Banal o.of Thermal Technicians 1447 E. Shaw Ave. Suite 150 Fresno, CA 93710 --- <br /> N <br /> Sensor (209)225-6698 <br />