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r <br /> AM <br /> Data CA for Tank System Ti htn os Test <br /> Y petro T'tQ <br /> PLEASE PRINT �Qls TANK TESTER <br /> 1. OWNER Property ® 9 a ll,4 <br /> j N&me Aadnea �� RSOreteMal Teleonons <br /> Tank(s) y/1'[^t` �' G <br /> Name Address Representative iNaonone <br /> 2. OPERATOR � `� , euii <br /> Name Address Teleonons <br /> 3. REASON FOR- <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED 14/ <br /> TEST AND WHEN Name Title Company or Affiliation Oat* <br /> Address Taleonone <br /> 5. WHO IS PAYING 5 0 <br /> FOR THIS TESTI Company.Agency of Individual Person Authorising Tine ieleonone <br /> Billing Address City State Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Ape Steel/Fiberglass <br /> 6. TANK(S) INVOLVED lm 3 d D.t7 A J' Y/0. L1 <br /> 7-,e.01 <br /> m f 31 1 AL �° s e C 4 <br /> Location T/.� Cover fills Vents Siphones Pumps <br /> 7. INSTALLATION <br /> DATA e0/X 4,err- Ll rf A 't <br /> North *driveway. Concrete.Black Top. Site.Tilsit"make.Drop <br /> Rest Sucnon.Remote. <br /> OI station.OIG Earth,ate. tubes.Remote Fitts Sire.Menifolded Which tanks 7 Make.l known <br /> 8. UNDERGROUND .{..� ,I Is the water over the tank 7 <br /> WATER Depth to the Water table 7 f 11 Yes No <br /> 9. FILL-UP Tanks to be filledL42�r. " a •� �' I-Al\� <br /> ace Arranged by <br /> Nam* Taleonone <br /> ARRANGEMENTS Extra product to"top off-and run TSTT. How and who to provide i Consider NO Load. <br /> Terminal or other conact ':'r <br /> :' � y <br /> for notice or in®ulfy ®e- !; } t✓ <br /> Company memo <br /> T*IepnOne <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER S 7-,* -n,0-rq,4 -Ter \ 4 � e <br /> � v <br /> INFORMATION Ufa >> .., :,- /✓11 . f <br /> OR REMARKS h'1 <br /> Additional information on any items above.Officials Or others to be advised when testing is in OfOgtess Or completed.Visitors at observers present <br /> during teat oto. <br /> Tests wen made on the above tank systems in accordance with test procedures proscribed for 4r0 14r <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: T <br /> Tank Identification Tight Leakage Indicated <br /> a Data Tested <br /> ®-0"7 <br /> This Is to codify that these tank systems wen tested on the date(s)shown.Those indicated as"Tight"meet the criteria established by <br /> 13. CERTIFICATION <br /> the National Fla Protection Asociation Pamphlet 329. <br /> Lawrence Tank Testing <br /> „fog - P.O. Box 407 ��..�...._ <br /> ey: ;gnaWt* <br /> Sen„NO. _,T . K^nisi.^= Downieville,California 95936 (916) 289-3109 <br /> Sonsor <br />