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CONFIDENTIAL <br />Technioal Solutions for the Industrial World. <br />UCISCO <br />Site Inprmation For Enhanced Leak Detection Sites <br />Submit Complatiad Form With Each Jobf <br />Techaicia Tla"n 12�,Job* D..JQ.122 -OY <br />site NAM <br />i'amaRegulatory dh:eativel New Installation? <br />-& Within im, afma? Uotestable, secondary containment? <br />.. _,rtsu vl�n d cm water tahim? I <br />b6mmwYc=mwur9 cmmftdmwmmmddW other): <br />art tTIEZ fijaaff) MO OW.M 7M (Pas MU (Pass/Fail) TK6 (Pass/Fain <br />, _at _. , M - <br />mmaLSumo _Pump (goetim) q_�ffira <br />21 CM <br />Q=d Cover 6ndifim <br />Tilt All CampongutnMCE <br />Types ofBackfill. <br />(poor) <br />Tank (Single Walt) �Mg iter erM <br />Lb es . (Mgi, WaM�aublr W�. - MOCO C§jjjFwU (Fibertranah) (other)_ <br />VentUnes MUM (Double Wall) (Steel) (INN—OF (other) <br />Vapor Rf=veryQm:a= (DoWeVall) (Steel) 0 er lass (other)— <br />(Assist) <br />m Construction I ) (Dirt) (Retrofit—baited to riser at I tank top) . (Retrofit—bolted to uianwdy) <br />su <br />M—MMM Well (Locations and deRthol <br />Water in Sump: YES /a) Depth from surlitow.— <br />Watwin tank pit YES Depth flmm Holf"e: <br />Compon'tio <br />Shape (draw picture-ifnamuRrY): <br />Depth to top: <br />Signature or site -parson verifying condition of site at and of installation:' l� eln cgzm&::::f <br />