Laserfiche WebLink
i I Datv#hart for Tank System Tioness Test <br />rO TIte <br />,PLEASE PRINT U TANK TESTER <br />1. <br />OWNER property E] <br />Tank(s)Telephone <br />Name Add-ress <br />Name Address <br />Representative <br />Rep resantative Telephone <br />2. <br />OPERATOR <br />15&-Zj /0 /!jam e <br />Name Address- <br />Telephone <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Lt�/4114e7j <br />Name Title <br />IA&-Af_ <br />Date <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />FOR THIS TEST? <br />Company, Agency or dividual Person AuthOFirl <br />________ <br />Title Telephone <br />Billing Address <br />le <br />Attention of: Order No. <br />Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />Capacity <br />/roe <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />7. <br />INSTALLATION <br />DATA <br />Location <br />/-V Attvz;r <br />W,4 y <br />North inside driveway, <br />Rea( of station, etc. <br />Cover <br />*4C& t.1 <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Vents <br />Size, Manifolded <br />Siphones <br />Which tanks? <br />Pumps <br />VA -z-7-, <br />Suction, Remote, <br />Make it known <br />8. <br />UNDERGROUND <br />WATER <br />Depth to the Water table <br />Is the water over the tank <br />Yes No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled - hr. - Date Arranged by <br />Extra product to "top off" and run TSTT. How and who to provide? <br />Name Telephone <br />Consider NO Lead. <br />Terminal or other contact <br />for notice or inquiry <br />Company <br />Name Telephone <br />10. <br />CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />T <br />11. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />A L III GALT H <br />Additional information on any items above. Officials or others to be advised when testing _V or observers present <br />during test etc. <br />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for F-wi—ro T <br />as detailed on attached test charts with results as follows: TANK rESTFQ <br />Tank Identification_ Tight Leakage Indicated Date Tested <br />7_7 <br />13. CERTIFICATION <br />'3,-3/ -95- <br />Date <br />77Z <br />Serial No. of Thermal <br />Sensor <br />This is to certify that these tank systems were tested onthe d e(s) shown. Those indicated as "Tight" meet the criteria established by <br />the National Fire Protection Asociation Pamphlet 329. T <br />TestingEFAITactor Signblure <br />P. 0, <br />Technicians AMS1140, CAtAFID.R140 9-592-A <br />