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I, <br /> Al DATA CHART <br /> For Use With . <br /> petro & <br /> Q1 LOCATION : 1 � 1 1- - NOD, \ <br /> w <br /> S <br /> Etreet No. end/or Corner City State Telephone No. <br /> Z <br /> z p 2 OWNER : <br /> Name Address Representative Position Telephone No. <br /> 3 OPERATOR : Tole hone No. <br /> eme �'"}� Dealer Mgr, or Other Address ( II different then Location ) P <br /> 4 REASON FOR TEST _ 1 � � � �� � ` ` Er " EE \ 1� <br /> z <br /> i= 5 TEST REQUESTED BY : <br /> c ) ln�\r <br /> i i y V Name Position Order No, Billing Address <br /> O <br /> Now J 6 SPECIAL INSTRUCTIONS : 4 ' <br /> 7 CONTRACTOR OR COMPANY MAKING TEST g _ ' ` 570 <br /> MECHANIC ( S ) NAME 00000wdoo, Jcill ) ` ` �2 <br /> 8 IS A TANK TEST TO BE YES 9 MAKE AND TYPE OF <br /> „ v~i MADE WITH THIS LINE TEST ? PUMP OR DISPENSERS. <br /> ~ <br /> w _ <br /> Q <br /> d ~ <br /> COVER I APPROXIMATE �J <br /> 10 WEATHER \^�y , 1 TEMPERATURE IN TANKS ` ' F� ' C OVER LINES �� `� � , BURIAL DEPTH <br /> f J <br /> C ncrete, Black Top, etc. <br /> 14 PRESSURE 15 VOLUME 16 TEST RESULTS <br /> IDENTIFY 13 LOG OF TEST PROCEDURES, <br /> 12 TIME <br /> EACH LINE AMBIENT TEMPERATURE, psi OR kPa READINGNET <br /> AS TESTED ( MILITARY) WEATHER, ETC, CHANGE CONCLUSIONS, REPAIRS AND COMMENTS <br /> BEFORE AFTER BEFORE AFTER <br /> 4E <br /> I <br /> ryO <br /> 4 tnrxvsr AV \ r)lakr) <br /> um ED Ce 0 i;Ej <br /> Ic <br /> Noon, Moo Mw <br /> ,) . <br /> Ll (C _C IUI.CCO - QJ � <br />