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PLLA:a. 11IiINI <br />1. OWNER Property C� <br />Tank(s) C�✓ <br />Data Chart Tank System Tightness <br />aetro ite <br />TANK TESTER <br />Name <br />2. OPERATOR _. SAmc <br />Name Adores Telephone <br />3. REASON FOR 44didZ449:16. 127arr,✓d& - CAi <br />9 <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED �% �"e/'����-r/ �' c" ��✓ - cc' '�c ares '"` +c <br />TEST AND WHEN Name Tine Company of AffiliationData <br />sArtt _ /' -G ?:,Years -- <br />Address Telephone <br />5. WHO IS PAYING <br />FOR THIS TEST? <br />Company. Agency, or Individual <br />Attention or: Onder No. Other Instructions <br />Identify by Direction <br />Capacity <br />Brand/Supplies <br />Grads <br />Approx. Ape <br />SWI/Fiberglass - <br />6. TANK(S) INVOLVED <br />p &00 <br />(__ <br />? <br />Pevy <br />geww <br />eft /A tiP <br />149..V <br />t <br />Gael D 4.110 <br />ot7'U <br />GsU 4.4<F <br />S®rc�H <br />Location <br />Coves <br />Fills <br />Vents <br />Siphones <br />Pumps <br />]. INSTALLATION�0�� �` <br />DATA �S G A/u40 S <br />�Nc <br />•` <br />•r <br />' <br />,,�� <br />0 7-r <br />North inside dtivewag <br />Real of station, etc. <br />Concrete. Black Top, <br />Earth, etc. <br />Sue. Titerill make, Drop <br />tubs. Remote Fills <br />Size. Manllolded <br />which tanks? <br />Suction, Remote, <br />Make it known <br />8. UNDERGROUND is the water over Lira tank <br />WATER Depth to the water tante Yea ❑ No <br />Tanks to be tilled he. Date Arranged by <br />9. FILL -UP Name Telephone <br />ARRANGEMENTS Extra product to "top off" and run TSTT. How and who to provide? Consider NO Lead. <br />Terminal or other contact <br />for notice or inquiry <br />Company Names Tttlspttom <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 obsetvers present <br />during test etc. <br />Tests were mate on the above tank systems in accordance with test procedurefs prescribed for t <br />12. TEST RESULTS u doWled on attachied toast chou with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />7V / V7 <br />/r J& <br />?Fn ..,. , n /wins rs/ / .7r.0/2- J Ljl <br />This is to certify that these tank systems were tested on tete date(*) shown. Those indlcated as "Tight'' moo the rAladai eslaifthad by <br />13. CERTIFICATION the Rational Fin Protection Asociallon Pamphlet 329. <br />orsra45' I //A/C- & <br />Testing Contractorof Compan y: $ qua <br />Swell No ut Thermal a Technicians Address - <br />sensor . ` �• 9 vie/ Z. <br />