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Data rt for Tank System Ti ss Test <br />` r <br />PLEASE PRINT TAN— K TESTER <br />1. OWNER Property ❑ 100Be1— O/L- /11Q9u u . , <br />Name Address Representative Telephone <br />Tank(s) 12/ <br />Name Address Representative Telephone <br />2. <br />OPERATOR <br />9-°p I+uN 51 37-1 <br />Name Address <br />lelegAone <br />3. <br />REASON FOR <br />TEST <br />T <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />1!CV� F1+{ t�+�61N� yrlbt3lC,: lf`ly <br />TEST AND WHEN <br />Name Title Company or Affiliation <br />Date <br />Address <br />Telephone <br />5. <br />WHO IS PAYING <br />M081(-.. ®IL KUtZr PISCHE2 vj(51 J <br />FOR THIS TEST? <br />Company, Agency or Individual Person Authorizing Tree <br />Telephone <br />Billing Address City State <br />Zip <br />Attention of: Order No. Other instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />G AST <br />Capacity <br />1010DO <br />Brand/Supplier <br />010MIL <br />Grade <br />Approx. Age <br />-t- <br />Steel/ Fiberglass <br />, T <br />10jow <br />M091 L <br />60 yr <br />i t VKf <br />SrGSL <br />103000 <br />440VIL <br />V&X§A0W <br />10+.415 <br />STMU <br />7. <br />DATA LLATION <br />Location <br />O <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />GOINSTASWM ND <br />Concrete, Black Top, <br />Earth, etc, <br />Fills <br />®Wli°{ J/ <br />Size, Titeilake, Drop <br />tubes, Remote Fills <br />Vents <br />to <br />` <br />Size. Manifolded <br />Siphons <br />A4 <br />Which tanks? <br />Pumps <br />rZONOTM <br />Suction, Remote, <br />Make if known <br />8. <br />UNDERGROUND <br />WATER <br />v t Is the water over the tank? <br />Depth to the Water table w a E] Yes No <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name <br />Extra product to "top off" and run TSTT. How and who to provide? Consider NO Lead. <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />10. <br />CONTRACTOR, <br />F Vi <br />MECHANICS, <br />� <br />any other contractor <br />involved <br />11. <br />OTHER <br />INFORMATION <br />Il Vii. <br />OR REMARKS <br />%t� � <br />U-111 <br />12. <br />TEST RESULTS <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 petro Tltp <br />as detailed on attached test charts with results as follows: """ T�S:N <br />Tank Identification Tight Leakage Indicated Date Tested <br />kE604Ae V,''- r ®'TL <br />6upex v Nul' #. - OL15 <br />1V fi <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(s) shown. Those indicated as "Tight' meet the criteria established by <br />the National Fire Protection Asociation Pamphlet 329. <br />/Zoio 309waLs, <br />_ Testing Contractor or Company. By: Signature <br />Mlle -K A I,. �S/ 57 s� r -,A t , <br />Technicians Address— <br />