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ata for Tank Systemi ess Test <br />PItASt PHINT TANK TESTER <br />1. OWNER Property W1 Quik Stop Markets, Inc. P.O. Box 5745 Fremont, Ca. 94537 <br />Tank(s) ® V. Jack Griffith A ,1`1 5) 657-8500 Rep1eaentaeee <br />Name Atddnaf Ramaaant.ti.. e'.r...n.. <br />2. OPERATOR <br />3. REASON FOR <br />TEST <br />(Explain Fully) <br />4. WHO REQUESTED Mr <br />TEST AND WHEN Name <br />5. WHO IS PAYING <br />FOR THIS TEST? ComPany. AQency Ot <br />Billing Address <br />State and County Regulations <br />Same <br />r"a <br />Same <br />Person Authotid" <br />N.. <br />ty or Affiliation <br />Telephone <br />Identify by Direction <br />Capacity <br />Brand/Suppler <br />Grads <br />Approx. Age <br />Steel/Fiberglas <br />6. TANK(S) INVOLVED #/ <br />0 opg <br />F <br />p <br />Via ia.3 .t/oeTN <br />rnIh SOK IN <br />/0, <br />e -,e <br />F <br />4-H -saurw <br />Location <br />Cover <br />Filk <br />Vents <br />Siphons <br />Pumps <br />]. INSTALLATION /Vo re rN °ic <br />QpNC�E TE <br />„ <br />N% <br />DATA /S�AN� <br />2 <br />/ <br />.E'E7n'A7' <br />North inside driveway, <br />Rear of station, etc. <br />Concrete, Black Top, <br />Earth, etc. <br />Site, Titafilh make. Drop <br />tub", Remota Fills <br />Site. Manitolded <br />Which tanks? <br />Suction, Remote, <br />Make it known <br />a. UNUMUMUUNU <br />WATER <br />9. Fill -UP <br />ARRANGEMENTS <br />10. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />11. OTHER <br />INFORMATION <br />�� ,t Is the water over the tank? <br />Depth to the Water table 11 Ya Eg—No <br />Tanks to be filled hr. Date Arranged by <br />Name Telephone <br />Extra product to"top off' and run TETT. How and who to provide? Consider NO Gad. <br />Terminal or other contact <br />for notice or inquiry <br />Company Name Telephone <br />OR REMARKS <br />Additional information on any items above. Officials or others to be advised when tasting 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 i0 Tl24' <br />12. TEST RESULTS as detailed on attar test charts with results as todows: <br />Tank Identification Tight leakage Indicated ----0 to Tested <br />&,:P& 7 ✓ — 02=9 �`t 2- a 2- <br />r/ m 7 <br />S <br />iuJ s _— <br />This is to conity that these tank systems were tested on the date(*) shown. Those Indicated as "Tight meet tete criteria sstabi i by <br />13. CERTIFICATION rete Nat►onaf Fire Protection Asodauon phNt 329. <br />J. Nestor Ba Cit Testing, Inc. <br />Date J. <br />Cootrkar of Company. y : Signature <br />See test 1 <br />So" No. of Thoffnal Technicians rssa <br />