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DATA CHART <br /> For Use With <br /> t � <br /> 1 LOCATION: <br /> m Street No.and/or Corner City State Telephone No. <br /> E w <br /> Z <br /> Z 3 2 OWNER: 0 <br /> O <br /> Name Address Representative Position Telephone No. <br /> 3 OPERATOR: <br /> Name Dealer Mgr.or Other Address(If different than Location) Telephone No. <br /> - -- 4 REASON FOR TEST_ / / <br /> 0 <br /> m~ 5 TEST REQUESTED BY: <br /> V O Name Position Order No. Billing Address — <br /> O <br /> J 6 SPECIAL INSTRUCTIONS: <br /> 7 CONTRACTOR OR COMPANY MAKING TEST ��/J/� N )/_ ✓J �( �C� /� <br /> MECHANIC(S) NAME <br /> 8 IS A TANK TEST TO BE ❑ YES 9 MAKE AND TYPE OF <br /> w MADE WITH THIS LINE TEST? Tom{ PUMP OR DISPENSERS <br /> NO ?COVER APPROXIMATE <br /> 10 WEATHER TEMPERATURE IN TANKS F C OVER LINES BURIAL DEPTH <br /> Concrete.Slack Top.etc. <br /> 14 PRESSURE 15 VOLUME 16 TEST RESULTS <br /> 11 IDENTIFY 12 TIME 13 LOG OF TEST PROCEDURES, <br /> EACH LINE AMBIENT TEMPERATURE, psi OR kPa READING NET <br /> :. TESTED (MILITARY) WEATHER, ETC. CONCLUSIONS, REPAIRS AND COMMENTS <br /> A <br /> BEFORE AFTER BEFORE AFTER CHANGE <br /> Xe%c)' / �--1 e�115 I Z�sg- <br /> TRIANGLE I YC OF SAMMENM <br /> R V BOX <br /> SACRAME O,CAUFOR IA 95823 <br />