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Data art for Tank yst i ess Test <br /> Ptr i <br /> PLFASE PRINT TANK TESTER <br /> 1. OWNER Property ❑ 14c tG LC <br /> Tenk(s) <br /> F1Name Address Reomsentsuve Telephone <br /> Name Atldress Representative Talepbnna <br /> r <br /> 2. OPERATOR 1¢G/�``�L Kk 3�lf �✓��r4u�Ltri�+ct� S7�cc(r!Toti Ga¢ <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST TEST <br /> (Explain Fully) <br /> 4. WHO REOUESTED <br /> TEST AND WHEN Name Title Company or ARdration Date <br /> Address Tereohone <br /> 5. WHO IS PAYING Glc.amu- ll 6 (.Vt., druG, <br /> FOR THIS TEST? Company.Agency cr Individust Person Aulhorhrirr6 Title Telephone <br /> Billing Address City State Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED _ <br /> �o .< R K <br /> Location Cover Fills Vents Siphones Pumps <br /> 7. INSTALLATION ®AV ev ZOO! k <br /> DATA 6+5&-,otmvr- L Aljip. k Sac�'cs s+ <br /> North Inside driveway. Concrete.Bleck Top, Size,Thefill make,Drop Suction,Remote <br /> Rear of station,etc. Earth,etc. lubes,Remote Fills Size.Monilolded Which tanks 7 Make if known <br /> B. UNDERGROUND Is the water over the tank? <br /> WATER Depth to the Witter table ❑ Yes 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. Now 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 /> 4R 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 test procedures prescribed for E/PIfO jltP <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: t— <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> _,0. f 1. 7—4? <br /> S 30o _ �_ , 607 6_ --- <br /> This Is to certify that these tank systems were tested on the date(s) o n.! � Ic ted as"Tight'meet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asocietion Pamphlet 329. </—� r <br /> 3-3f —K <br /> Date � _� <br /> TestingC ttrttur Or ompany. By: Signature <br /> _'777 ;c <br /> Serial No of Thermal Technicians - <br /> t / Address <br /> Sensor <br />