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Jr t <br />PLEASE PRINT <br />Data ift for Tank System <br />P—Tote <br />TANK TESTER <br />Tigieqp Test <br />/J- 2y -F( <br />1. <br />OWNER Property ❑ <br />Tank(s) ❑ <br />Neme Address Representative Telephone <br />• n�l0ZAd t j <br />Name Address Representative Telephone <br />2. <br />OPERATOR <br />Name Address Telephone <br />3. <br />REASON FOR <br />Z9 <br />TEST <br />(Explain Fully) <br />4. <br />WHO REOUESTED <br />��%�` f A SA c� �, <br />TEST AND WHEN <br />Name Title Comoanv or Affiliation Date <br />Address Telephone <br />5. <br />WHO IS PAYING <br />FOR THIS TESTI <br />Company, Agency or Individual Person Authorizing Title Telephone <br />Billing Address City State zip <br />Attention of: Order No. Other Instructions <br />6. <br />TANK(S) INVOLVED <br />Identify by Direction <br />EA S 7- <br />Capacity <br />/0_.,000 <br />Brand/Supplier <br />Grade <br />Approx. Age <br />30 <br />Steel/Fiberglass <br />7. <br />INSTALLATION <br />DATA <br />n <br />0- 1 <br />ort inside driveway. <br />Rear of station, etc. <br />Cover <br />6 a •-'(0_je fc <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Vents <br />Size, Manifolded <br />Siphones <br />Which tanks? <br />Pumps <br />Suction, Remote, <br />Make if known <br />8. <br />UNDERGROUND <br />WATER <br />Is the water over the tank? <br />Depth to the Water table © Yes No . <br />9. <br />FILL -UP <br />ARRANGEMENTS <br />Tanks to be filled hr, Date Arranged by <br />Name Telephone <br />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 Name Telephone <br />Cr t S o c At i o <br />10. <br />CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />11. <br />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 />12. <br />TEST RESULTS <br />Tests were made on the above tank systems in accordance with test procedures prescribed for PPtfO jltP— <br />as detailed on attached test charts with results as follows: ^"K. itta <br />Tank Identification Tight Leakage Indicated Date Tested <br />FAST p , P SPC <br />13. CERTIFICATION <br />Date <br />fsFC;Z <br />Serial No. of Thermal <br />Sensor <br />This is to certify that these tank systems were tested on the dates) shown. Those Indicated as "Tight' meet the criteria established by <br />the National Fire Protection Asociation Pamphlet 329. <br />Testing Contractor or Company. '-' By: Signature <br />—5 L -.e --tee,, Sv- <br />Technicians Address <br />