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TSC 1000 Leak Detector Tester <br /> DATA COLLECTION AND REPORT FORM <br /> Facility Name: M14-5 e.r 4 K e F-co <br /> Facility Address: I YoS C 4L r F02 N r sT <br /> c-`scat-0�j �C9 <br /> Facility Phone: .7oY- 9'33 76 i Test Date: - /it-/e'Ic <br /> Test Contractor: Ck,1g Pra 0 d�4515 iJ t,q-�K, , <br /> Address: <br /> Contractor Phone#: ICO-66c!) - 4YY3 <br /> Product Leak Serial Line s®rbn slow Flow Pays <br /> Detector Number PSI PSI mow Rate or <br /> Model PSI at 10 PSI Fail <br /> 3ti}'e-"S lig-0S� 0 2'34 --oc.3B z 3 13 i o ! eFn eA5-S <br /> le6- I-AZ !r6 n56 0 239'7-0637 2 3 13 /O 2c -)i e ss <br /> y23Y' - oio31 z j iZ $ 3 CFH iAYS' <br /> Test <br /> Technician: ALy,rJ L, Signature: <br /> Date: Time: 1030 <br /> Comments: fEirL.li=d�Gy <br />