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ii <br />Data Chart for Tank System Tightl�ss Test <br />petr2j fe <br />PLEASE PRINT 1ANK TESTER <br />1. OWNER Propenr ❑ <br />❑ NawS• AOdr.ss <br />Reo•..enuu., id•pnona <br />Tanks) <br />Nam• AddUn <br />This Is to certify that these tank systems were tested on the dele(s) shown. Those indicated as -right- meet the cMeris established by <br />13. CERTIFICATION the National Fire Protection Asocistion Pamphlet 329. <br />G -.3'0 - 90 `v1•9RK Stli4 W 8�� K�,P SiyDc>S Tf/ES <br />O.[. at: S.on•wa. <br />)Owl. - _S77 <br />!�G .tl � S/.3 �/OI �t'f>TLEi+�1�9id Li1NE La <br />2. <br />OPERATOR <br />N•me Add,.$% <br />Te:aonon. <br />;. <br />REASON FOR <br />NIA/N7FiVAit/cE <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />e cdmDan, of Adution o• <br />Title a <br />TEST AND WHEN <br />Add,.%$ <br />t.l.onon. <br />5. <br />WHO IS PAYING <br />FOR THIS TEST? <br />Como+nr. wo•ncr or lndividuai Pend. Autno,:rind <br />iiu. telaohon. <br />aillind Addr.ss Cit, <br />state Zio <br />Attention of: Order No. Omer Instructions <br />identify by Question <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />IST <br />6. <br />TANK(S) INVOLVED <br />,✓oRr/a NRi�'EGuCAR <br />/S YRS - <br />L <br />sou of <br />/Z o0o <br />E Co <br />UNLfi3DED <br />/S t 5 <br />^02 o r <br />�iREE <br />/Z ooa <br />AGa�% <br />SSPE,p <br />aLfi�oED <br />%S YR5 - <br />STEEL <br />Location <br />07 - OF <br />Covet <br />Fills <br />Ii <br />Vents <br />Siphones <br />Pumps <br />REiriioTE <br />7. <br />INSTALLATION <br />oCRC <br />T•i Tio•J ' <br />CoA-, <br />I/ JA/i'rH <br />D Roe TUBE <br />1r <br />Z <br />NO <br />TUX N51 /A <br />DATA <br />.5 <br />•Suction. <br />Notch inside duveway. <br />Rear of uat; etc. <br />Concrete, Stack Too. <br />Earn, ata <br />Size. Tit.fill make. Onto <br />tubes. Ramon Fills <br />Size. M.nifold.d <br />VWh:cn links! <br />Remot.. <br />Make G kno—n <br />S. <br />UNDERGROUND <br />to 138 t <br />Is the water over the tank? <br />11 Yes ® No <br />WATER <br />Depth the water table <br />Tanks to be filled hr. Date Arranged by <br />Narne Telephone <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Extra product to -top oii- and run TSTT. How and who to provide 7 Consider NO lead. <br />Terminal or other contact <br />for notice or inquiry <br />Company N+nN Ts1eDhOM <br />10. <br />CONTRACTOR. <br />MECHANICS. <br />any other contractor <br />involved <br />11. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />Additional information on any items above. Officials or other to be advised when testing is in progress or completed. Visitors or observers pesen: <br />' <br />during test etc. <br />Tests were made on the above tank systems in accordance with test procedures prescribed for Fw1ro If <br />12. <br />TEST RESULTS <br />as detailed on attached test charts with results as 9011OWS: <br />~ ;'u' <br />Tank Identification Tight leakage Indicated <br />Date Tested <br />EGvLA TiGNT r oZS G•P. N <br />19 S'v�E88 <br />E r t. oa N. <br />7-9 Sr E 8 <br />uN�ADE r� G N T t. /_r do N. <br />This Is to certify that these tank systems were tested on the dele(s) shown. Those indicated as -right- meet the cMeris established by <br />13. CERTIFICATION the National Fire Protection Asocistion Pamphlet 329. <br />G -.3'0 - 90 `v1•9RK Stli4 W 8�� K�,P SiyDc>S Tf/ES <br />O.[. at: S.on•wa. <br />)Owl. - _S77 <br />