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Data fart for Tank System Tiglwss Test <br />petro T to 7� <br />PLEASE PRINT TANK TESTER <br />1. <br />OWNER Property <br />rKI <br />P.Q 4 2r -Fr 7114 <br />7-8:5-e0 <br />Tank(s) , <br />Name <br />_ FL- <br />Q-win74/7 c.a <br />Address Representative <br />. _ S/�3 7 <br />Telephone <br />Name Address Representative <br />_ <br />Telephone <br />2. <br />OPERATOR <br />= '� <br />/ C_> s. Czo9946 <br />&7,5 <br />Name <br />Address <br />Telephone <br />3. <br />REASON FOR <br />TEST <br />' <br />(Explain Fully) <br />, <br />4. <br />WHO REQUESTED <br />Ii _SM to NZjSM5 <br />TEST AND WHEN <br />Name _ <br />- l' <br />Title Company or Affiliation <br />2� 7 <br />Date <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />/k <br />1. .ler - <br />- FS <br />FOR THIS TEST? <br />Company. Agency or Indiviqual <br />�?Q �r S7 s�ti ���n�.tiT <br />Person AuthorizingTitIs <br />e _ 9 ie 3 ] <br />Telephone <br />Billing Address City State <br />.Cr F <br />Zip <br />Attention of: <br />Order No. Other Instructions <br />6. <br />TANK(S)INVOLVED <br />Identify by Direction <br />i <br />Capacity <br />n <br />Brand/Supplier <br />Grade <br />- D <br />Approx. Age <br />? <br />Steel/ Fiberglass <br />ff <br />�- <br />r< <br />lS' <br />1. <br />INSTALLATION <br />DATA <br />Location <br />fc'r-o„1sr <br />C-0 I- <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />Co•u <br />? <br />Concrete, aleck Top. <br />Earth, etc. <br />Fills <br />Size, Titetill make. Drop <br />tubes. Remote Fills <br />Vents <br />Sue. Manifolded <br />Siphons& <br />Which tanks? <br />Pumps <br />Suction, Remote, <br />Make it known <br />8. <br />UNDERGROUND <br />WATER <br />w/ Is the water over lthe tank T <br />Depth to the Water table ry Yes Ivc> No <br />u <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name <br />Extra product to "top off' and run TSTT. How and who to provide? Consider NO Lead. <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <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 others to be advised when testing is in progress or completed. Visitors or observers present <br />during test etc. <br />12. <br />TEST RESULTS <br />Tests were made on the above lank systems in accordance with test procedures prescribed fortro Itte <br />as detailed on attached test charts with results as follows: i�T <br />E I r <br />Tank Identification Tight Leakage Indicated Date Tested <br />/ L <br />— <br />�/�'E <br />•� <br />07-9 <br />13. CERTIFICATION <br />/-2Ci-" <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 />the National Fire Protection Asociatlon Pamphlet 329. <br />Date <br />Setup No ul Thermal Technicians <br />Sensor <br />