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J_ DATA CHART <br /> For Use With <br /> 1 LOCATION• 342G 1 fit' 1 J`-''u D <br /> Street No.and/or Corner City State Telephone No. <br /> `hwj W <br /> `# 2 OWNER: <br /> Name Address Representative Position Telephone No. <br /> S OPERATOR: <br /> Name ( Dealer,Mgr,or Other Address(If different then Location) Telephone No. <br /> 4 REASON FOR TESTqw <br /> Ask <br /> o <br /> ►- S TEST REQUESTED BY: <br /> y N Name Position Order No, Billing Address <br /> i <br /> 6 SPECIAL INSTRUCTIONS: <br /> } 7 CONTRACTOR OR COMPANY MAKING TEST <br /> MECHANIC(S) NAME <br /> a B IS A TANK TEST TO BE 2—YES 8 MAKE AND TYPE OF <br /> Of.- <br /> .�� FMADE WITH THIS LINE TEST? PUMP OR DISPENSERS <br /> ><a ❑ NO <br /> COVER �y� ® APPROXIMATE <br /> 10 WEATHER TEMPERATURE IN TANKS '24 F -C OVER LINES "�-+� - BURIAL DEPTH <br /> Concrete,Black Top,etc. <br /> 11 IDENTIFY 12 TIME 13 LOG OF TEST PROCEDURES, 14 PRESSURE 16 VOLUME 16 TEST RESULTS <br /> EACH LINE (MILITARY) AMBIENT TEMPERATURE, psi OR kPa READING NET <br /> AS TESTED WEATHER, ETC. BEFORE AFTER BEFORE AFTER CHANGE CONCLUSIONS, REPAIRS AND COMMENTS <br /> q30 000 wflo -,00\c) <br /> uo <br /> UQUAL 9co I <br /> i <br /> 130 �- � , 4�; -- •�tS <br /> 44 - , <br /> C)o A-0 - <br /> q tom ! <br /> S---lE:-D 9\-�4 c, <br /> _ rc115S <br /> icx�� CsP <br /> r:t�n, <br />