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Data 4*art for Tank System Titess Test <br />ro Titer <br />TANK TESTER <br />a <br />Address <br />Address <br />Rapreaenlative Telephone <br />Representative Telephone <br />3. <br />REASON FOR <br />.nynune <br />TEST <br />�---- <br />r�5 Tz�r.4t <br />(Explain Fully) <br />-- <br />--.---- -- <br />4. <br />WHO REQUESTED <br />TEST AND AND WHEN <br />"°m° ' tll;yt�e <br />----__-__ compsoABxia Data - <br />Address Telephone <br />5. <br />WHO IS PAYING <br />FOR THIS TEST <br />�� �- <br />Cinfpany, Agency or Individual -- <br />.- <br />Person Authmizi g - Title --- Telephone - -- <br />Billing Address <br />------------------ <br />CItY State Zip <br />Attention of: <br />Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/Fiberglass <br />7. <br />INSTALLATION <br />DATA <br />Location <br />I'V A WW <br />t„ �, y <br />Cover <br />� <br />$ Ae <br />Fills <br />Vents <br />Z <br />Siphons <br />r(/oLf� <br />Pumps <br />:jsr�Tsrl�l/ <br />North inside driveway, <br />Real of station, etc. <br />Concrete, Black Top. <br />Earth, etc. <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Size_, Manifolded <br />Which tanks? <br />Suction, Remote, <br />Make it known <br />a, <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 />NameV - -- Telaphon—�+- <br />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 Name Telephone — <br />10. <br />CONTRACTOR, <br />MECHANICS. <br />any other contractor <br />involved <br />— <br />-- --- -- -- .—� — — <br />11. <br />OTHER <br />- -- <br />--.--- <br />INFORMATION <br />---- - <br />-- ---- -- <br />OR REMARKS <br />- --- - --- — -- _. _.------- <br />Additional information on any items above. 01ficials 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 tank systems in accordance with test procedures prescribed for p tp <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight <br />Leakage Indicated Date Tested <br />13. CERTIFICATION <br />Date <br />.777, <br />Serial No. of Thermal <br />Sensor <br />This Is to certify that these tank systems were tested on the d e(s) shown. Those indicated as "Tight" meet the crllisda established by <br />the National Fire Protection Asoclation Pamphlet 329. <br />Testing ctifillactor rI.9 y.��rav:..., Sign ture <br />_ P. 0.i <br />Techniciani-------- -- }f'�iA ---��rd4sw�s---- <br />�AORAtoI�>��; = <br />