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4 <br />EASE I'IfINT <br />1. OWNER Property [� <br />Tank(s) [ <br />L.a4,a to Ot mi i dim iz►yste i ,, i ,s i est E C E v E <br />pttm T tP <br />TANK TESTER MAR 31 1988 <br />G1�c r <br />Name c4_�FBP_.�_ ___7 z 7z wFs ��.r-,� QUIK STOP. MARKETS <br />Address Representative Telephone <br />L l ! cG S7n tp /97 [Gf FZE"rr� D A" i tn4._. <br />Name <br />13. CERTIFICATION <br />Date <br />Serial No. of Thermal <br />Sensor <br />This is to certify that these tank systems were tested on the date($) shown. Those indicated as "Tight" meet the criteria established by <br />the National Fire Protection Asociatlon Pamphlet 329. <br />&61-m & <br />Technicians <br />4. F: . a g 1///z <br />-- <br />ovM..aomauvs Telephone <br />2. <br />OPERATOR <br />Name <br />Address <br />Telephone <br />3. <br />REASON FOR <br />TEST <br />---- <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />/ ! 7-9 <br />TEST AND WHEN <br />Name <br />Title Company or Affiliation Date <br />Addreu <br />Telephone <br />r <br />5. <br />WHO IS PAYING <br />FOR THIS TEST? <br />Company. Agency or Individual <br />Person Authorrring <br />Tide Telephone <br />Billing Address <br />City <br />State ZAP <br />Attention of: <br />Order No. Other Instructions <br />Identify by Direction <br />Capacity <br />Brand/Supplier <br />Grade <br />Approx. Age <br />Steel/ Fiberglass <br />6. <br />TANK(S) INVOLVED <br />10/ <br />!c <br />+�-L */ d. <br />3 <br />Location <br />Cover <br />Fills <br />Vents <br />Siphons <br />Pumps <br />7. <br />INSTALLATION <br />srofec <br />CpN� <br />a <br />u <br />DATA <br />NA <br />/gym <br />Fjeo,t) V- <br />North inside driveway, <br />Rear of station, etc. <br />Concrete, Black Top, <br />Earth, etc. <br />Size, Tilelill make, Drop <br />tubes, Remote Fills <br />Suction, Remota, <br />Size. Manifoided <br />Which tanks? <br />Make it known <br />6. <br />UNDERGROUND <br />q/� Dag2, <br />&0N7W/A,1 `-- <br />Is the water over the tank? <br />WATER <br />Depth to the Water table X1;1 <br />11 Yes No <br />9. <br />FILL -UP <br />Tanks to be filled hr. <br />Date Arranged by <br />ARRANGEMENTS <br />Extra product to "top off" and run TSTT. How and who to provide? Consider NO Lead. <br />Name Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company <br />Name Telephone <br />10. <br />CONTRACTOR, <br />MECHANICS, <br />Z��� • —» <br />any other contractor <br />involved <br />11. <br />OTHER <br />INFORMATION <br />OR 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 pptr0 T1S <br />12. <br />TEST RESULTS <br />as detailed on attached test charts with results as lollOWS: <br />t ns <br />Tank Identification Tight <br />Leakage Indicated <br />Date Tested <br />O ✓ <br />A^ OO <br />3 <br />/, ✓ <br />Q <br />./ <br />13. CERTIFICATION <br />Date <br />Serial No. of Thermal <br />Sensor <br />This is to certify that these tank systems were tested on the date($) shown. Those indicated as "Tight" meet the criteria established by <br />the National Fire Protection Asociatlon Pamphlet 329. <br />&61-m & <br />Technicians <br />4. F: . a g 1///z <br />