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1 <br /> i <br /> Data hart for Tank System Tightness Test <br /> PLEASE PRINT petro TOP_' k. j TAN <br /> K TESTER <br /> 1. OWNER Property <br /> Tank(s) Name Address Representative Telephone <br /> Name Address Representative <br /> Telephone <br /> 2. OPERATOR <br /> Name Address Telephone <br /> 3. REASON FOR <br /> TEST v — <br /> (Explain Fully) <br /> 4. WHO REQUESTED i• '' = =t-c <br /> TEST AND WHEN Name Title Company or Affiliation <br /> Dace <br /> Address Telephone <br /> 5. WHO IS PAYING c c' <br /> FOR THIS TEST? p!^r.A encu or Individual Titl telepnone <br /> 7 grit �C_ Penon AuMonzin9_ <br /> G " %� f <br /> Billing Address City ` <br /> State Zip <br /> Attention of: Order No. Other Instructions <br /> Identify by Direction Capacity Brand/Supplier Grade Approx.Age Steel/Fiberglass <br /> 6. TANK(S) INVOLVED 1 0 _�� <br /> 7�C �e, 4— <br /> Ul- <br /> Location Cover Fills Vents Siphons Pumps <br /> 1. INSTALLATION Ftz�_ i,—T-, <br /> DATA C + C C n <br /> .)"Tc_(?(__ <br /> North inside driveway. Concrete.Black Top. Size,Titefill make.Drop Suction.Remote. <br /> Rear of station.etc. Eanh•etc. tubes.Remote Fills Size,Manifolded Which tanks 7 Make if known <br /> 8. UNDERGROUND Is the water over the tank l <br /> WATER Depth to the Water table U Yes No <br /> 9. FILL-UP Tanks to be filled ice hr. �`Z 6 Date Arranged by L tFN y <br /> ARRANGEMENTS Extra product to"top oft"and run TSTT. How and who to provide t Consider NO Lead. Name Telephone <br /> Terminal or other contact (w <br /> for notice or inquiry— 13 r <br /> Company Name TvIephone <br /> 10. CONTRACTOR, <br /> MECHANICS. <br /> any other contractor <br /> involved <br /> 11. 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 <br /> 12. TEST RESULTS as detailed on attached test charts with results as follows: R90 R� <br /> Tank Identification Tight Leakage Indicated Date Tested <br /> k = ( = s r <br /> C_ 7 2 s <br /> L:t,, — —;. <br /> This is to certify that these tank systems were tested on the dates)shown.Those indicated as"Tight"most the criteria established by <br /> 13. CERTIFICATION the National Fire Protection Asociation Pamphlet 329. <br /> Datey �», (cr3 Lawrence Tank Testing <br /> P.O. Box 407 Signature <br /> Serial No.of Thermal Technicians Downieville,California 95936 <br /> Sensor (916) 289-3109 <br />