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b/ 1 <br />Capacity <br />/Ti3O <br />PLEASE PRINT <br />1. <br />OWNER Property <br />Steel/Fiberglass <br />5fcbize <br />Tank(s) <br />2. <br />OPERATOR <br />3. <br />REASON FOR <br />TEST <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />5. WHO IS PAYING <br />FOR THIS TEST? <br />1 Tight oss <br />Data Chart i <br />petro de <br />TANK TESTER <br />t p iC <br />Address <br />t'•c s5c c. /y /4. rt <br />Address <br />t% Lt,c.'zri. <br />ny, ApaneY or Inolrleuel Persun Authorli� --� <br />Address - -- -- - City <br />Dn of: Order N. <br />or Affiliation <br />Tide Telephone <br />State Zip <br />Other fristructinns <br />Identify by Direction <br />6. TANK(S) INVOLVED <br />Capacity <br />/Ti3O <br />Brand/Supplier <br />(�/.v <br />Grade <br />�� y <br />Approx. Age <br />Steel/Fiberglass <br />5fcbize <br />Location <br />7. INSTALLATION �0'�`/�r(�i*./ <br />DATA r4 �' <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />Concrete. Black Top, <br />Earth, etc. <br />Fills <br />Size, Titefill make, Drop <br />tubes. Remote Fllis <br />Vents <br />- <br />Size, Menifolded <br />Siphones <br />�tiio�.trr <br />Which tanks 7 <br />Pumps <br />Suction, Remote. <br />Make if known <br />a. uNDERGROUNU Is the water over the tank i' <br />WATER Depth to the Water table 11 Yes 19 No <br />Tenks to be filled hr. Date Arranged by <br />9. FILL -UP Nemo Telephone <br />ARRANGEMENTS* <br />Extra product to "top off" and run TSTT. How and who to provide? Consider NO Lead. <br />10. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />11. OTHER <br />INFORMATION <br />OR; REMARKS <br />12. -TEST RESULTS <br />s <br />Terminal or other contact <br />for notice or inquiry <br />Company Name Telephone <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 prtro TrfP <br />as detailed on attached test charts with results as follows: 1j'1K <br />Tank Identification Tight I Leakage Indicated I Date Tested <br />This In to conity that these tank systems were tested on the d e(s) shown. Those Indicated as "Tight' meet the criteria established by <br />13. CERTIFICATION the National Fire Protection Asoclation Pamphlet 329. <br />Dorf® <br />Company. <br />Testing ontrector r Cmny. By: Signature <br />"7771P. 0. �. _ - ' <br />Send NO. d Tttermd echnkians <br />Sensor <br />