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Data ClOt for Tank System Tight*s Test <br /> petro T'tP <br /> PLEASE PRINT TAN_K T�ESTER —^ <br /> t. OWNER Property a <br /> Tank(s)s Nama rN. Address Reolesentalive Teieonona <br /> Name Address Reoresenptive TaleonOne <br /> 2. OPERATOR '� 7 <br /> Name Address Nepnone <br /> 3. REASON FOR <br /> TEST <br /> (Explain Fully) <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Title Comoanr Or Aftiliation oaks <br /> Address Teleonone <br /> 5. WHO IS PAYING <br /> FOR THIS TEST? COmoany.Agency or Individual Person Authorizing Title THeonone <br /> Billing Address City State Zip <br /> Attention of: order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade A <br /> pprox.Age Stool/Fiberglass <br /> 6. TANK(S) INVOLVED T®,Fe3 9�'0 <br /> location Cover Fills Vents Siphones Pump <br /> 7. INSTALLATION) - <br /> DATA of ,ET yL �iiT� <br /> North Insure dtrvewey, Controls.Black Top, Sire,iitella make.crop <br /> Rear of station,etc. Earth,etc. vibes,Remote Flits Site,MenSuction,Remot{. <br /> ifolded Which poke 1 Mab J known <br /> 8. UNDERGROUND L(//),�� lathe water over the rant f <br /> WATER Depth to the Water table `v _ o vas in <br /> No <br /> 9. FILL-UP Tanks to be liked hr.®Date Arranged by <br /> ARRANGEMENTSName Teleonone <br /> Extra product to"top off"and run TETT. Now and who to provide? Consider NO Lead. <br /> Terminal of other contact <br /> for notice at inquiry <br /> Comosay Name Teleonone <br /> 10. CONTRACTOR, <br /> MECHANICS, <br /> any other contractor <br /> involved <br /> 11. OTHER r Gt/ ,f13 <br /> INFORMATION <br /> OR REMARKS <br /> AdditbnN information on any items above.Officials or oehers to be advised when testing is in progress or completed.Visitors or observers present <br /> d test stL <br /> 12. TEST RESULTS <br /> Tarts wens she"On this above tank systems in accordance with test procedures prescribed for petro jts <br /> as detalied on attached cast Charts with results as follows: 1.0,0 <br /> Tank Ida tan Tight Leakage Indicated <br /> �. Q� p Dau Tested <br /> 7� <br /> This Is to Certify that the"tank systema wars tasted on the date(s)shown.Tho"Indicated as"Tight""Tight"matt the Criteria established by <br /> 13. CERTIFICATION <br /> the Natl Protection Asoeiatbn Pamphlet 329, <br /> 0 Lawrence Tank Testing <br /> D <br /> 9/ P.O. Box 407 <br /> Seng ignat <br /> S—IX a Th«mv ••^^�•ts^• Downieville,California 95936 <br /> (416) 289-3109 <br />