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POB 36 26515 N. SACTO. B11 <br />Affarba-TicsfiTHORNTON, CA. 95686. <br />(209) 794-0102 (800) 524-9087 <br />CONTRACTOR/ENGINEER <br />ORDERING TEST / <br />SITE: vi <br />OPERATOR <br />Station# <br />INE & LEAK DETECTOR <br />TEST REPORT <br />TEST DATE I 1L -7--71C4 <br />OWNER <br />SITE ADDRESS bLff f �—M E k�? �j ADDRESS <br />C <br />�- C CSL C IJ C& 52 -r -J-7-- <br />PHONES j5/ - 5 a' PHONE <br />............. .. .�.. ......... r.,.-..... �.. ...... ...... _... ........ M'� . •.. ....� •_.N� —..� �, w ..r.rMn•J.�. 7 Wl 1•xn FlNh. _ ra �r.ne 9n M...... .. ......... <br />REASON FOR TEST <br />LINE(s) ONLY IXFANK(s)-LIN <br />LIN <br />E(s)-LEAK DET. <br />.TANK(s)-LINE(s)-LEAK DET. <br />MAKE & TYPE OF PUMP <br />ORDISPENSER �^ r�Fj/Y� 1 J <br />COVER OVER /+ � <br />LMS C L l���- '�II, r L -7 J 1 Ll <br />APPROX BURIAL .n ^ / <br />WEATHER ' CLSC <br />LOCATION SKETCH <br />>(ukc-n r.)►.�---F —c � n(=( <br />G� CD �`7 <br />DIE <br />PRESSURELu <br />SUCTION <br />SHOW STREETS, BLDOS. TANKS. ISLANDS; PIPING <br />(IF KNOWN). PUMPS OR DISPENSERS <br />LEAK DETECTOR <br />FTA LEAK DETECTOR TEST INFORMATION Calibrate <br />10 PSI <br />No. <br />E <br />Y TYPES.• Product <br />LD Serial Opening Test <br />VX Number Resiliency Time Leak Rate <br />In Seconds MLIMin <br />Functional <br />Element <br />Holdin PSI <br />ering <br />PSI <br />Yes / <br />No . <br />XLD P/N 116036-5 <br />MODELBFLD (XL <br />P/M 116039-5 <br />C PLD P/N 116030-5 <br />XLP P/N 116035-5 <br />DLD P/N116017-5 <br />BFLD P/N 116012-5 <br />OTHER <br />Notes <br />CONTRACTOR. <br />CERTIFICATIONI <br />LINE TEST RESULTS <br />�� TESTS RE'REMADEON771ELINESYSTEMSASNOTED INACCORDANCEWITHTEST <br />PROCEDURES PRESCRIBED FOR AS DETAILED ON 771E TEST CHART ON SIDE 2 <br />OF 7711s FORM If'1T11 RESULTSASF0LLOIfS: <br />TECHNICIAN. I <br />ECR <br />SIONA <br />LfNE IDENTIFICATIOlel—� NET VOLUME CHANGE PER HOUR <br />U E <br />L1C # 97-1]43 <br />Train cc N,,,,, <br />'7 <br />A / FAIL / INCONCLUSIVE <br />PAk S -y FAIL / INCONCLUSIVE <br />. <br />Tree S;gnmae <br />i ti=S l '� �/ <br />PASS / FAIL / INCONCLUSIVE <br />FEATURING PETR -TITE <br />LINE TESTER <br />P / .._FAIL / INCONCLUSIVE <br />