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A r.. a.aw w«r ao• rvr rwrrea wtwav rr. . ««.a -«w .a«wa <br />a. <br />PLEASE PRINT TANK TESTER <br />1. OWNER Property ❑ c'. S t® c & f ® ti <br />❑Tank(s) Name Address Representative <br />Name q Address Representative <br />2. <br />OPERATOR <br />Brand/Supplier <br />Grade <br />- <br />Approx. Age <br />3 o <br />Name <br />3. <br />REASON FOR <br />TEST <br />,u v <br />(Explain Fully) <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Name <br />5. <br />WHO IS PAYING <br />tion $C- t <br />7. INSTALLATION <br />DATA <br />Q� <br />No It Inside driveway. <br />Rear of station, etc. <br />Cover <br />ASP 4 et <br />Concrete, Black Top, <br />Earth, etc. <br />FOR THIS TEST? <br />Company, Agency or <br />Siphones <br />Which tanks? <br />Pumps <br />s u C <br />Suction, Remote, <br />Make if known <br />Bitting Address <br />Attention of: <br />y st . S 40r c , A/ 00-3 %CJQ 9 c1 L <br />.v S id c C_ t<; o Y e S <br />or <br />Address <br />Person Authorizing Title <br />City stair <br />Order No. Other Instructions <br />Telephone <br />Telephone <br />Telephone <br />,td`ci <br />Date <br />Telephone <br />Identify by Direction <br />6. TANK(S) INVOLVED Nw 0c. t <br />Capacity <br />®oo <br />Brand/Supplier <br />Grade <br />- <br />Approx. Age <br />3 o <br />Steel/Fiberglass <br />a,C <br />w VO4-eh-le <br />r 12.0, 0400 <br />3 o <br />tion $C- t <br />7. INSTALLATION <br />DATA <br />Q� <br />No It Inside driveway. <br />Rear of station, etc. <br />Cover <br />ASP 4 et <br />Concrete, Black Top, <br />Earth, etc. <br />Fills <br />3 7 f <br />Size, Titefill make, Drop <br />tubes, Remote Fills <br />Vents <br />f f <br />2 <br />Size, Manifolded <br />Siphones <br />Which tanks? <br />Pumps <br />s u C <br />Suction, Remote, <br />Make if known <br />8. UNDERGROUND Is the water over the tank 7 <br />WATER Depth to the Water table ® _ ❑ Yes ® No <br />Tanks to be filled hr. Date Arranged by <br />9. PILE-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 Name Telephone <br />10. CONTRACTOR, <br />MECHANICS, <br />any other contractor <br />involved <br />11. OTHER <br />INFORMATION <br />OR REMARKS <br />12. TEST RESULTS <br />� N Allc 't A ; r" 01-1 e d S ®r✓ <br />t/�lFi /ate: Lt 4/t ON VR'Fbier (_e264'Cd"j tfl'Pt c e!) A:)- ed <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 />as detailed on test charts with results as follows: <br />Tank Identification Tight Leakage Indicated Date Tested <br />® Le — <br />tr t 0,00vCAA 11®c -_ n 2a C!DM Ina /St - QA <br />This is tot �es that these tank system were ed the date(s) shown. Those Indicated as •Tight^ ramal the orad by <br />13. CERTIFICATION <br />�e,�2 �-a( to a& <br />Onto esti�ontrractor or Company. By: SigiWature <br />Serial No. of Thermal Technicians Address <br />Sensor <br />