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1 if II_7 C, _3 ,c -7 <br />' Data Chart for'Tank System Tightness Test <br /> P tro alp !` <br /> -s <br /> TANK TESTER - <br /> 1 OWNER _ r <br /> ProP4rtY ❑ } "'" ' K t <br /> Name AdtlrQps <br /> Tanks) ❑ % Talephone!f*, -� <br /> F Name r a.daresa ~�- J~Teiaanone <br />' 2 OPERATOR ep-Leis " a <br /> o <br /> Name t AC 034 _ �� <br /> '.TOledhpm! <br /> 3 REASON FOR TEST =Y <br /> 5 (Explain Fully) <br /> f 4 WHO REOUESTEA <br /> TEST AND WHEN Name r, Tlva Carrlpany or At Illatlon,_, -Ca If_ <br /> Adtlreas Taloonone <br /> b WHO IS PAYING ' ' <br /> ..t <br />' sr FOR THIS TESTI Company Agency or iftw,iduai M1� =� Person Authormnp •T{Ileielephane <br /> +r 8WIng Address <br /> ' y r �♦ �Y ^' CItY _ Stats - <br /> r ` At Qntlon of - _ x <br /> T Order No other fnatructicna <br />' B TANK(S) INVOLVED tCentily by Direction Capetlty Gratle Aporox Age ee Albergi�.a ~ <br /> LLQ as !C. �6OC�,� .� ? y <br /> r 7 ' <br /> 7 INSTALLATION Loc lion Co*or Fiiia vents Siphon% o-r,aa <br /> DATA <br /> Norttt im,de arlveway CdAteta B220TQp Silt, Tife'ill rake Drop St.:Ca AemCte <br /> Bear of stahcn rM Earth atC loos. Rcmoie Ems Size Manotdltltd wh�cn tank_^ f,I,kr II Irnown <br />' 8 'UNDERGROUND h@wal9r Ov@r ^afar Rl <br /> WATER Depth to water table It known ❑ Ye, -39, Nd <br /> 9 FILL-UP_ — <br /> ARRANGEMENTS Tanks to beldled �—�7" l0Qata Aregngeclby I ..•_� o �-. �+� <br />' Nsme <br /> HourTe,Qcnono <br /> 10 TECHNICIANS / <br /> 11 OTHER <br /> INFORMATION t` <br /> IOR REMARKS ` <br /> Aceilicn3i Information on any items aeov* officials or athsr3 to be AdvliLed when IOitrng I*In Wcgle4a Of CCnlplQted Vlsltofs cr caervpry present <br /> durlrq test etc � <br /> r <br /> 12 TEST RESULTS Teats were matle on the above tank systems In accordanee wlih teat procedures prescribed for FPIro T 10 <br /> as details on etteeheC feet ctterta wi wa aTa— <br /> Tank ldertrfhcaUon Tr;nt Within Toteramra Owe of Tolerance Date Te_r1 <br /> I <br /> 13 CERTIFICATION This Is to certify thas these tank systems ware leafed on th,00411e(s)shown Those indlestod sa'Tight mast the cnterls establlshod by the Nstldnai F"ra <br /> Proteclloe Assoclation Pamphfat 3.9 <br /> Naf person cortifying <br /> Jb <br /> lll �./ �++ F4 yQ :1n�Jcntr foto Cu•':an5 <br /> I x uI ha 3f Th rf`�d, $enao• cdn.leat,on loom Car ACCre_y 1 r1 <br /> RECEIV ❑ !i' Ei 1 ✓ 17J; <br />