Laserfiche WebLink
ataart far n Systemi s Test <br /> U tf r t# i <br /> P`r.ASE PRINT TANK TESTER m <br /> 1. OWNER Proper, ❑ 114C/F!G _-- <br /> ) <br /> Tank(S ❑ Name Address R®Drefentafrv® P One <br /> TNe h <br /> Name Address RepresmtNiee TelepAnna <br /> 2. OPERATOR A!-!,,r` 3VC_A�®S4,v-tet *�f�ect� SYct�/Tc s G�4 <br /> Nome Address Yliephone <br /> 3. REASON FOR <br /> TEST 7c- sr <br /> (Explain fully) - — <br /> 4. WHO REOUESTEO <br /> TEST AND WHEN "'"" Title co4^any or Anrir.tron Dole <br /> Address Telephone <br /> S. WHO IS PAYING _ FAL ' - 1/ L ty OC,VG, <br /> FOR THIS TEST? Company Agency or Individual Person Authoriri True Te+eohone <br /> Billing Address CMT State Zip <br /> Attention of! Order No. Other InotruchonS <br /> Identify by Direction Capacity Brand;Supplier Grade A <br /> ppox Ape Steeb!fitierglasE <br /> 6. TANK(S) INVOLVED <br /> Location Cover fills Vents Siphones Pumps <br /> 7. INSTALLATION ,A' CeA4,� Z" 7.1", <br /> DATA 6+5&-.WnvT 5"kc41;40 <br /> Nonh inside dtieewet. Concrete.Blscs Too. Sire,Thefill mesa.Drop Sucvon.Remote. <br /> Rear of station,etc Earth.etc. tubes.Remota Fill$ Sire.Manuolded Which tanks t Wake it known <br /> 8. UNDERGROUND Is the water over the tank i <br /> WATER Depth to the Water table ❑ res No <br /> Tanks to be filled hr. Date Arraby 9. FILL-UP Mama 494ephons <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 /> Company Nome Telephone <br /> 10. CONTRACTOR, <br /> MECHANICS. <br /> any other contractor —�—----— <br /> involved <br /> 11. OTHER <br /> INFORMATION <br /> qR 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 wen made on the above tank systems M accordance with test procedures prescribed for If <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: , <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> YG SSp <br /> Ad S o0 0o <br /> This is to ce"Ity that these tank systems were tested on dee dete(s) rc tad as"Tight"nwet the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asocintion Pamphlet 329. F <br /> 3-;tf <br /> Date <br /> -04 <br /> TSI e. filing C ttfRtw of o lwnr Br Signtture <br /> S"NO of Thermal KAmcuns f - •• Adores$ <br /> somm <br /> - 1. ' r ..! � i•'r.. rot! C:-->�'� <br />