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sta Chart for Tank•Systln Tightness Test <br />PLEASE PRINT <br />1. OWNER Property <br />Tanks) 1-Z�L <br />IT'1 riZ 6 ) <br />Name Address Representative <br />Telephone <br />Name Address Representative <br />Telephone <br />2. OPERATOR <br />Y 4 r S <br />Name Address <br />Telephone <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />w S —N 14 rl <br />4. WHO REQUESTED <br />TEST AND WHEN <br />Name Title Company or Affiliation <br />Date <br />Address <br />Telephone <br />1� <br />5. TANK INVOLVED <br />qC,,,, <br />Use additional lines <br />for manifolded tanks <br />Identify by Direction <br />tsjj <br />Capacity <br />lt>g <br />Brand/Supplier <br />t,,J >7t-�a-1-tom-,- <br />Grade Approx. Age <br />>JNr_ 2M,6 nt <br />Steel/Fiberglass <br />,P t <br />� <br />��< <br />re / <br />GG,.JLA <br />v <br />10R <br />r t it <br />C, UP A L <br />R, UL^t <br />, t t, <br />WAS 7f <br />6. INSTALLATION <br />DATA <br />Location <br />North inside driveway, <br />Rear of station, etc. <br />Cover <br />��r{�. <br />Concrete. Black Top, <br />Earth, etc. <br />Fills <br />� �1 <br />Size, Titefill make. D'i'Op� <br />tubes, Remote Fills 1,j4 <br />Vents Siphons <br />'' U <br />Size, Manifoldedt 4 Which tanks? <br />Pumps <br />+� 5L pct«Z <br />Suction, Remote, <br />Make if known <br />7. UNDERGROUND <br />WATER <br />Is the water overthetank? <br />Depth to the Water table ' "t ,R h=—� ❑ Yes L111Jo <br />8. FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr. Date Arranged by <br />Name <br />Extra product to 'top off" and run tank tester. How and who to provide? Consider NO Lead. <br />` <br />Telephone <br />Terminal or other contact <br />for notice or inquiry <br />Company Name <br />Telephone <br />9. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />10. 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 during test, etc. <br />11. TEST RESULTS, tj <br />Tests were made on the above tank systems in accordance with test procedures prescribed for <br />as detailed on attached test charts with results as follows: <br />Tank Identification Tight Leakage Indicated <br />Date Tested <br />✓�1� <br />q <br />-d- l �t� �rooZ CsP <br />/c -zo-q <br />Z C EA, -rte t,007 GP N <br />- (- I <br />r� 4-, OOZ 6 P.+ <br />-zo _ <br />12. SENSOR <br />CERTIFICATION <br />Date <br />13. Thio is to certify that these tank systems were tested on the date(s) shown. Those Indicated as "Tight" meet th, criteria established by the <br />Natlond <br />ai Fire Protection AssoaHoe Pamphlet 32a <br />Technicians <br />PHILIP F. DELGADILLO <br />1:0:122510940 <br />Serial No. of Thermal Certification M <br />Sensor <br />2 C <br />Cartifir tion M 9 2 — ! 0Z 2+ <br />testing contractor orcompany. ter. signature ` <br />Address <br />PN6827 <br />4� <br />ti <br />