HomeMy WebLinkAbout0499 IYANNOUGH ROAD - HAZMAT �Iqq l�nnou�4-, �oaB, 4en ;s
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=' TOWN OF-BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
pq_��V4
NAME Shell nil Company, 1145 Reservoir Ave. , Cranston, R.I. 02920
Service Station at:
ADDRESS 11yannis Airflert & Rte. 28 VILLAGE HVnnnis, MA
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
OR CHEMICAL
Left side of Building 8,000 Gasoline 9 years Fiberglass
II II II II 8,000 It 9 years Fiberglass
II II 11 II 8,000 II years Fiherg acs
(Give same information for any additional tanks on reverse side of card)
DATE OF PURCHASE OF EACH: 1. 1971 2. 1971 3. 19-71 4.
DATE OF FIRE DEPARTMENT PERMIT: Original dated 11/19/28--copy of latest permit attached,
TESTING CERTIFICATION SUBMITTED:
PASSED DID NOT PASS
C` e C�0rrtMCMfarajt4 of ) US.uchusefto
Department of Public Safety—Division of dire Prevention
1010 COMMONWEALTH AVE., BOSTON
REGIs 'CRATION
. BMtNSTABLE.........................AP41......1 ,
I 19.19..
(city or Town) (lit*)
This is to certify that.............. ..GA.................................................has, in accordance with the
provisions of Chapter 148, Section 13, of the General Laws, filed with me a certificate of registration set,
ti r ha .. . ... . ............ it ...................................................is the holder of the license granted
..................................................................19........ for the lawful use of the building(s) or other structure(s)
situated or to be situated at.........IY•amugb..x.d..and..Fitee....28,..Hyanni,.S".Nk.............................................
(Street end Number)
as related to the KI-1-PING, STORAGE, MAN U1,A(,'1•L'lt ' 0I{;•5ALE OF F 1,,1,R'1111A13LES OTi EXROSIVES.
..........................................................................................
(�itTn lu ■nrl Official Title)
Town Clerk Barnstable
Note: A certificnie of registration rnu.t he filed on or before April 30th of each year.
(THIS NEGisTRATION 11UST BE: CONSPRAJOUSLY POSTED ON TIIE PREMISES.)
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- j xkLL -OIL! LvivirAN < .
PURCHASE ORDER
PURCHASE ORDER No. aA�
En1oRUISI 1Qi4 (I4''�a/N �. . •r, ,� e/ 'w"
IS this Nuriiher on Invoices,Togs,Boxes,etc.)
54 TO'SHELL,OIL COMPANY'' THEREIN CAlLEf7 "$HELL") BLANKET ORDER No.
t igw Dt, If Applicable)
I f t t DATE
IMPORTANT
4 t3 � Mail Invoice In•Quadruplicote with original and
r `one copy cf prepaid freight or express bill,•
acknowledgment, shipping notices and bills of-
lading to SHELL'OIL COMPANY:
r.
HEREIN CALLED"CONTRACTOR"
,Ship !'t'+s' F.O. B. a TERMS
t Via
•1. IF delivery is not or cannot be mode promptly by Contractor must so notify Shall immediately,and Shell reserves the'right IA nce is order
in whole or in part:To give such notice, or for.any further information,contact at Shell's address abo"ve.
�.2. 'f;aouling is not.,specified skip by cheapest Toute commensurate with required delivery dote. Do not insure parcel post or express shipments unless specifically
�hr s'fruclad to do.so.
3. No charges will be allowed forgacking or,cartode unless specified in quotation.
4.r$how cosh discount terms on Invoice;All invoices for material on which no cash discount is allowed will be paid 30 days from invoice date.
5- Mail Duplicate Bill of lading and Shipping List to Consignee of dsslinatlon.
QUANTLTY t., MATERIAL OR SERVICE PRICE
e. :0Wo
05,
raft WON-*
- '
!It
UAW
'
SHELL OIL
aIn
PURCHASING DEPARTMENT
Show o asted Vendor's Homes here-
Maker
To be completed by requesting Depnrlment:, n surg
Makerr >r' Total Est. ° y
r&Departm Dote
ont Cost S
a
sr
livor Room Reqn.
Dole Do xsi�r
Requiredw�,,r�,� To 'y��'~'"`� 9 ,+� Job,No. No.
saw
To be
Used For No! - Own } -
r.l Use Approved ,
Chorge Work Resole By '
Account- (�rdsi — A.F.E.
13. '+w+�„+..*.a+�"..i".• } .. + ' �,.,+R!e:iwr wlq+r.a�T...�"'sl+�r,Tw,nnen.�'.+ww.+.`ee ers-x+*n�.•,e+�.,:..v.e•-ee..n�.+.n..w.s e*���...^" � `' -
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;v �{ems tp.t t; ttts;t kc tzik+Yt Ilt±tilfi41t3F Ml6i Sly#f#�T7 f #lfj�3Trf1,Y,I,,: st ys hst j t}Mr
t
NEW ADDRESS - as of 4/16/82
Mr. Robert Gardella
Shell Oil Company
400 Blue Hill Avenue
Westwood, Mass. 02090
I
TOWN OF BARNSTABLE
UNDERGROUND FUEL AND CHEMICAL STORAGE SYSTEMS
I-JOH :VI RRE
NAME XWOR:`T ROTA-11y SHEt—T SKRVIC.19
ADDRESS VILLAGE
LOCATION OF TANKS: CAPACITY: TYPE OF FUEL AGE: TYPE:
j OR CHEMIICAL
(Give same information for any additional tanks on reverse side of card) Q
DATE OF PURCHASE OF EACH: 1. 2. bl 3. 4. G 7
DATE OF FIRE DEPARTMENT PERMIT:
0
TESTING CERTIFICATION SUBMITTED:
PASSED DID NOT PASS
NAME LOCATION
Shell Oil Co. Iyanough Rd. & Rte. 28
1145 Reservoir Ave. Hyannis (Traffic Circle)
Cranston, R. 1. .0?-92O
BOOK & PAGE DATE GRANTED AMOUW STORED
37/33 11/19/28
77/64 4/12/57
77/157 1/z6/66 Total 27,100 gals._
DATE PAIR
1973 - March 26 R ?7 7 r�lh :6, t
V!AR 3 119/ P Rk; 1ylu
�INAR 19 1975
MAR 1 . i9 7
. i
Hyannis Airport Rotary & Rte. 28
Hyannis, MA
38Ay CAPE_,C`_-w M ZNs. (N JO @Ay— ,aOOPMERs
I� . ?I� R' 8M
TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. ( ! PARCEL NO. bo
aq
ADDRESS OF TANK: I1YA14'NIS AIRPORT TRAFFIC C RC VILLAGE: /7 1 i AMAL.
Number Ytr��t
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE)': 400 BLUE HILT, DRIVE, WESTWOOD. MA 02090
OWNER NAME: SHELL OIL COMPANYU PHONE: 617-326-8210
INSTALLATION DATE: 1971 BY: ED6ARD SiEMINSKI
INSTALLER ADDRESS: 1032 AMERICAN LEGION IM* WESTPORT, NA 'CERT.1-JO.
*TANK LOCATION:
(mamcn=aC TANK {_OOAT 2 ON W 2 TH RQCPQCT TO nu 2 LD I NO)
CAPACITY 8M TYPE OF TANK FIBERGLASS , AGE 16 YRS. FUEL/CHEM I CAL GASOLINE
TESTING CERTIFICATION EXXj PASS C ] FAIL DATE June 3+ 1987
LEAK DETECTION CY] CHECK IF N/A TYPE/BRAND RED JACKET
ZONE OF CONTRIBUTION [X1 YES C I NO DATE TO BE REMOVED !
FIRE DEPT. PERMIT ISSUED C I YES C I NO DATE
CONSERVATION [ ] CHECK IF N/A DATE a
BOARD OF HEALTH TAG NO. C ] DATE
jr
r
PLEASE PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD A
TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. 1 k2d PARCEL NO. O a
ADDRESS OF TANK.
HYANI+7IS AIRPORT TRAFFIC CIRCLE� VILLAGE: �l 411-1-\
Numbmrr atr^wqwt
MAILING ADDRESS ( I F DIFFERENT FROM ABOVE) : 400 BLUE HILL DRIVE, WESTWOOD, MA
OWNER NAME: SHELL OIL COMPANY PHONE: 617-326-8210
INSTALLATION DATE: 1971 BY• EDWARD SIEMINSKI
INSTALLER ADDRESS: 1032 AMERICAN LEGION HHY, WESTPORT, MA 'CERT.1-40.
*TANK LOCATION:
(ommoR I aC TANK l_OQAT 2 ON W S TH mama CT TO mU 2 1_D 2 NO)
CAPACITY 8M TYPE OF TANK FIBERGLASS AGE 18 YRS. FUEL/CHEMICAL GASOLINE
TESTING CERTIFICATION C X I PASS C ] FAIL DATE June 3, 1987
LEAK DETECTION C Y] CHECK IF N/A TYPE/BRAND RED JACKET
ZONE OF CONTRIBUTION C' YES C ] NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C ] YES C ] NO DATE
CHECK IF N/A DATE
CONSERVATION [ ] Q(J
BOARD OF HEALTH TAG NO. C ] DATE
� y
PLEASE PROVIDE ,A SKETCH SHOWING THE TANK LOCATION .ON THE HACK OF THIS_ CARD
TOWN OF BARNSTABLE - UNDERGROUND FUEL AND CHEMICAL STORAGE REGISTRATION
MAP NO. 3 PARCEL NO.
ADDRESS OF TANK: YA NIS AIRPORT TRAF ZC CIRCLE VILLAGE: J I VA 0I
Numb.0r ObrORw!
MAILING ADDRESS ( IF DIFFERENT FROM ABOVE) : 400 BLUE HILL DRT.VE. WEST.WOOD. N.A. 02090
OWNER NAME: SHELL OIL COMPANY PHONE: 617-326-871.0
INSTALLATION DATE: 199 BY: EDWARD SIEMINSKI
INSTALLER ADDRESS: 0I32 AMERICAN LEGIUN HWY, WE9PORT, MA •CERT.140.
*TANK LOCATION:
(owscRzom TANK LOCATION WIT" RKOPQCT TO nux"DINO)
CAPACITY BM TYPE OF TANK FIBERGLASS AGE 18 YRS. FUEL/CHEMICAL GASOLINE
TESTING CERTIFICATION [ )Y PASS C I FAIL . DATE June 3, 1937
LEAK DETECTION Cy] CHECK IF N/A TYPE/BRAND RED JACKET
ZONE OF CONTRIBUTION [ ] YES C j NO DATE TO BE REMOVED
FIRE DEPT. PERMIT ISSUED C I YES C I NO DATE
CONSERVATION [ ] CHECK IF N/A DATE /�
BOARD OF HEALTH TAG NO. C ] DATE 3 114AW
Lr' 007 1
* , PLEASE .PROVIDE A SKETCH SHOWING THE TANK LOCATION ON THE BACK OF THIS CARD
'4r Tm===a- 4 of 9U.Sar4nafts
WSW=
DEPARTMENT OF PUBLIC 5,'1,FL -,1 T- -DIVISION OF FIRE PREVENTION
P"" E
Date
G
TO MAINTAIN AN EXISTING/NEW UNHRGr AU�-;J.*;U 3TONE FACILITY
In accordance with the provisions or7 this permit to maintain an
T
existing/new underground storage aCilitY is granted to:
Location of property: HyANNJ S ALRpogT TgAFFTC CTgcT,F,. HyAN-,qT,(; , MA
Owner of property: SHELL OTT, COMPANY
Full name of person, --,r corDoratlon
Restrictions: -
A)
Fee Paid:$zv_x (M.G.L.A. Chapt. 1433' Sec . 10A),
Form F.P. 290
Part 4 This permit will expire -0e
')f F! ED -t or appoi- -d designee
Date .re H�Ac of Fire Dent. or appoi. -d designee
i Omn r% r- r 900, n—i-
sww
6
X IV
ih
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k
7-
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r
icat!6n for Underground Storage Tanks
FIRE DEPT.
FIRE DEPT, STATE USE ONLY CIEVPU711111111
Copy to be certified by local fire departnelat 1° Number
y
and: POSTED AT STORAGE FACILITY Oate ece3
lug .0
f�
a • •
Notific lion is required by Federal law for all underground tanks that have been 4. pipeline facilities (including gathering line) regulated under the Natural Gas
a i
used to store regulated substances since January 1,1974.that are in the ground as of Pipeline Safrt�Act of 1968,or the Haiarduus Liquid Pipeline Safeq Act of 1979.or
May 11.1986.or that are brought into use after May,8,1986.The information requested whichisantmrastatc pipeline facility regulated under State laNs:
is required by Section 9002ofthe Resource Conservation and Recovery Acl,(RCRA), 5.surface impoundmcnts.pits.ponds.orlagoons:
as amended. 6.storm'water or waste water collection systems:
7.flow-through process tanks:
The priman purpose of this not iticaIion program is to locate and ecaluale under- g liyuid traps or associated gathering lines directic related to oil or gas product ion and
ground tanks that store or hase stored petroleum or ha!ardous substances. It is gathering operations:
expected that the information you proside will be based on reasonable as'ailable 9. storage tanks situated in an underground area (such as a basement. cellar.
records.or.in the absence of such records.your knowledge.belie):or recollection. mineworking,drift,shalt.or tunnel)it the storage tank is situated upon or above the
I Who Must Notify? Section 9002 of RCRA.as amended. requires that. unless surface of the floor,
exempted.owners of underground tanks that store regulated substances must notify What Substances Are Covered? The notification requirements apple to under-
(a) in
State or local agencies of stotherage
existence n their tanks.Owner means o round storage tanks that contain're ulated substances.This includes any substance
tat in the case of an underground storage tank in use on Nosember 8. 1984,or g g' g i
brought into use after that date.any person who owns an underground storage tank defined as haiardous m section 101 (14) of )lies Comprehenstse Environmental i
Response.Compensation and liability Act of 198010ERCLA),with the exception of
used for the storage,use.or dispensing of regulated substances,and
Ibl in the case of any underground storage tank in use bel'orr November 8.19ti4. those substances regulated as haiardous waste under Subtitle C of RCRA. It alga
but no longer in use on that date,any person who owned such tank immediately bigion: includes petroleum,e.g..crude oil or am fraction thereof which is liquid at standard
the discontinuation of its use. conditions of temperature and pressure(60 degrees Fahrenheit and W7 pounds per
What Tanks Are Included? Underground storage tank is defined as any one or square inch absolute).
combination of tanks that(1)is used to contain an accumulation of'-regulated sub- Where To Notify? Completed notification forms should be sent to the addrusm
stances."and(2)w hose s olume(including connected underground piping)is 10('i or given at the top of this page.
more beneath the ground.Some examples are underground tanks storing:I.gasoline. When To Nolifv? 1.Ow ners of underground storage tanks in use or that have been !
used oil.or diesel fuel.and 2.industrial sohents,pesticide,herbicides or fumigants. taken out ul operation after.lanuan I. 1974.but still in the ground.must notify by
.a What Tanks Are Excluded? Tanks remowd from the ground are not subject cat %la%8. 1986.2.Ou ners who bring underground storage tanks into use after May8.
notification.Other tanks excluded from notit',cation are: 19W can st notify within ill da%:s of bringing the tanks into use.
1.farm or residential tanks of 1.)00 gallons or less capacity used lie storing rnotor fuel
for noncommercial purposes: Penalties: Any owner who knowingly fails to notify or submits false information
2.tanks used for storing heating oil for consumpike use on the premises where scored: shall be subject to a civil penalty not to exceed$10,000 for each tank for which
3.septic tanks: notification is not given or for which false information is submitted.
INSTRUCTIONS,
Please q•pc or print in ink all items except"signature"in Section V.Thisform must by completed for Indicate number of
each location containing underground storage tanks.If more than 5 tanks are owned at this location. continuation sheets
photocopy the reverse side,and staple continuation sheets to this form. attached
OWNERSHIP OF TANK(S) 11.LOCATION OF
Owner Name(Corporation,Individual,Public Agency,or Other Entity) (If same as Section t,mark box here❑)
SHFT T T T ('OMP ANY Facility Name or Company Site Identifier,as applicable
Street Address
4n(l RT TTF HTT.T. T)RTI7F SHEI-1 OIL COMPANY
County Street Address or State Road,as applicable
NoRFnT.V HYANNIS AIRPORT TRAFFIC CIRCLE
City State ZIP Code Co'
ntyY
WESTWOOD MA 02090 BARNSTABLE
Area Code Phone Number City(nearest) State ZIP Code
617-326-8210 HYANNIS MA 02601
Type of Owner (Mark all that apply
Private or Indicate Mark box here if tank(s)
Current ❑ State or Local Gov't Corporate
t� number of are located on land within ❑
❑ Former (GSA facility I.D. w
❑ Federal Gov't ❑ Ownership tanks at this an Indian reservation or
no. uncertain location on other Indian trust lands
CONTACT •N AT TANK LOCATION1
Name(If same as Section t,mark box here ❑) Job Title Area Code Phone Number.
08
Eli
IV.TYPE OF NOTIFICATION,
❑ Mark box here only it this is an amended or subsequent notification for this location.
CERTIFICATIONV.
i
I certify under penalty of law that I have personally examined and am familiar with the information submitted in this and all attached
documents,and that based on my inquiry of those Individuals immediately responsible for obtaining the information, I believe that the
submitted information is true,accurate,and complete.
Name and official title of owner or owner's authorized representative Signature Date Signed i
R.F,,. GARDELLA, SR. DIST. ENGINEER 1W A ` � G
Owrbir Name(from Section 1) SNFT.T. C1 T T. C OMP A NYocation(from Section 11)XYANNT S Page No. of_.��
ea
(Complete for each tank at this focatior�),
VI.DESCRIPTION OF UNDERGROUND STORAGE TANKS
Tank Identification No.(e.g..ABC-123),or Tank No. Tank No. Tank No. Tank No. Tank No.
Arbitrarily Assigned Sequential Number(e.g.,1,2,3...) 3
1.Status of Tank
i Currently in Use
(Mark all that apply®) Temporarily Out of Use Q] Q Q Q Q
Permanently Out of Use
Brought into Use after 5/8/86 Q Q] Q Q Q
2.Estimated Age(Years) S 15 13
3.Estimated Total Capacity(Gallons) SH
4.Material of Construction Steel Q Q Q Q Q
(Mark one®) Concrete
Fiberglass Reinforced Plastic
Unknown Q Q Q Q Q
Other,Please Specify
S.Internal Protection Cathodic Protection
(Mark all that apply®)
Interior Lining(e.g.,epoxy resins) ® EX3
None O O 0 O
Unknown Q Q Q Q Q
Other,Please Specify
I 6.External Protection
Cathodic Protection
(Mark all that apply®) Q Q Q Q Q
i
Painted(e.g.,asphaltic) Q Q Q Q Q
Fiberglass Reinforced Plastic Coated [X] Wl
None 0 Q Q 0
Unknown Q Q Q Q
1
Other,Please Specify
7.Piping Bare Steel Q Q Q Q Q
(Mark all that apply®) Galvanized Steel Q Q Q Q Q
Fiberglass Reinforced Plastic ® [ Q Q Q
Cathodically Protected Q Q Q Q
Unknown Q Q Q Q Q
8
Other,Please Specify
"r
f 3 8.Substance Currently or Last Stored a. Empty t�_1_,q.,i UT-1 FOL-1 Q Q
j In Greatest Ouantity by Volume
1 b. Peir leurn
Diesel
(Mark all that apply®)
Diesel
U Q 0 0 Q
Kerosene Q Q Q Q 0
Gasoline(including alcohol blends) [$'] ® Q Q
Used Oil Q 0 Q Q Q
Other,Please Specify
c. Hazardous Substance Q 0 Q Q Q
Please Indicate Name of Principal CERCLA Substance
I OR
Chemical Abstract Service(CAS)No.
Mark box 13 if tank stores a mixture of substances
d. Unknown
9.Additional Information(for tanks permanently
taken out of service)
a. Estimated date last used (mo/yr) /
b. Estimated quantity of substance remaining(gal.)
c. Mark box®if tank was filled with inert material
(e.g.,sand,concrete) Q Q Q Q Q
Owrer,Narne,(from Section 1) ocatlon(from section 11) A NN T S Page No. o1
.6
Tank Identification No.(e.g.,ABC-123),or Tank No. Tank No. Tank No. Tank No. Tank No.
Arbitrarily Assigned Sequential Number(e.g.,1,2,3...)
1.Status of Tank Currently in Use E Q Q
(Mark all that apply®) Temporarily Out of Use
Permanently Out of Use
Brought into Use after 5/8/86
2.Estimated Age(Years)
3.Estimated Total Capacity(Gallons)
4.Material of Construction Steel Q Q Q Q Q
(Mark one M) Concrete
Fiberglass Reinforced Plastic ®
Unknown Q Q Q Q Q
s
Other,Please Specify
5.Internal Protection Q Q Q Q Q
(Mark all that apply®) Cathodic Protection
Interior Lining(e.g.,epoxy resins) ® CKLI ® Q Q
Norte Q Q Q Q Q
Unknown Q Q Q Q Q
j Other,Please Specify
I
i 6.External Protection Q Q Q Q Q
� Cathodic Protection
(Mark all that apply®) Painted(e.g.,asphaltic) Q Q Q Q Q
Fiberglass Reinforced Plastic Coated EX] [K] END Q Q
None Q Q Q Q Q
Unknown
Other,Please Specify
7.Piping Bare Steel Q [Q Q Q Q
(Mark all that apply®) Galvanized Steel O O O O
Fiberglass Reinforced Plastic ® [ QQ Q
Cathodicalty Protected Q Q Q Q
Unknown Q Q Q Q Q
Other,Please Specify
8.Substance Currently or Last Stored a Empty Dt E51__! rd'-i Q Q
in Greatest Quantity by Volume b. Petroleum
i (Mark all that apply M) Diesel Q Q Q Q Q
Kerosene Q (Q Q Q
Gasoline(including alcohol blends) ]: IND Q' Q
Used Oil Q Q 0 Q 0
Other,Please Specify
c. hazardous substance
Please Indicate Name of Principal CERCLA Substance
OR
Chemical Abstract Service(CAS)No.
Mark box®if tank stores a mixture of substances
d. Unknown
9.Additional Information(for tanks permanently
taken out of service)
a. Estimated date last used(mo/yr)
b. Estimated quantity of substance remaining(gal.)
c. Mark box®if tank was filled with inert material
(e.g.,sand,concrete) O O 0 L=7
i
I — SURE-TEST COW.
3 y
Data Chart for Tank Sstem Ti htness Test � 1
IL 1 � Monvi!ie,R..I.04838
USING KENT-MOORE CORPORATION TANK TIGHTNESS TESTER MODEL 1000 40'-769 3033
Copyright 0 Kent-Moore Con oration 1977 OiY 7, 5 2514
MISSION
I 1. OWNER Property Shell Oil Co. , 400 Blue Hill Drive Westwood MA 02090
Tanks
a) ® Name - Address Representative Telephone
Name Address Representative Telephone
2. OPERATOR Shell ervice Station.
Name AiAat Circle, Hyannis. MA Telephone
3. REASON FOR
TEST
(Explain Fully) Routine Iesting
4. WHO REQUESTED Dennis ul 1 i van Engineer Shell Oil Co. 4-87
TEST AND WHEN Name Tide Company or Affiliation ate
Address Telephone
5. WHO IS PAYING --Dennisl l i v n Engineer - - -
FOR THIS TEST? Company,Agency or Individual Person Authorizing Tide Telephone
Billing Address City State zip
Attention of: Order No. Other Instructions
Identify by Direction Capacity Brand/Supplier Grade Approx.Aye Stsrd/Fib"Im
6. TANK(S) INVOLVED
#2 8,000 Shell Super Unlea ed
#3 8,000 Shell Super Unlea ed
Location Cover Figs Vents Siphons Pumps
7. INSTALLATION
DATA
North Inside driveway, Concrete,Black Top. Size,Thef ll make,Drop Suction,Remote,
1 Rear of station,etc. Esrtha etc. tubes,Remote Fills SW,Manif~ Which tanks? Make If known
S. UNDERGROUND is the water over the tank?
WATER Depth to the Water table below tank bottom yes No
Tanks to be filled hr. Date Arranged by
9. FILL-UP Name Telephone
ARRANGEMENTS Extra product to-top off'and run TSTT. How and who to provide? Consider NO Lead.
Terminal or other contact
for notice or inquiry
Company Name Telephone
i
10. CONTRACTOR, - P.O. Box 117, Manville. R1 0283�
MECHANICS. Cumberland.
any other contractor
involved
11. OTHER All lines tested separately - lines tight.
INFORMATION
OR REMARKS
Additional information on any items above.Officials or others to be advised when testing is in progress or completed Visitors orobswwn praeM
during test etc.
Tests wens made on the&bow tank systems In accordance with test procedures~bed for KsM-Moore Tank Systems TlOhfmsa
12. TEST RESULTS Tester Model 1000 as detailed on attached tees charts with results as follows:
Tank Identification Tight Leakage Indicated Deb Tested
1 yes +.039 6-3-87
I 2 yes +,047 6-3-87
es -.021 6-3-87
This Is to corny that these tank systems were tested on the date(*)shown.Those Indicated as"Tight"nisei by
13. CERTIFICATION the National Fin Protection Asodatbn Pamphlet 329. -
June 3, 1987 Robert Champagne Sure-Test Cor .
Dais Tatung Coditnictor or Y. y: Signature
15r_ 1699 P.O. Box 117, Manville, RI 02838 401-769-3033
Senal No.of Thermal Technicians Address
Sensor