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TECHNOLOGY FOR TANKS <br />AND THEIR ENVIRONMENT <br />LEAK D <br />tECTOR REPOR <br />TANKNOLOGY MODEL <br />So# 3:Y3(a? <br />Site (312. Facility #, / / 19• DATE _ tl/�/1 moi/ <br />Address _&;,5 0 L -y v I --)LE <br />City/St I -A -r ep-Pp CA_ Ztl' 3,36 <br />Sub Pu mp:nedJacket,Tokheim,Gilbarco,Sennett,DresscrWayne,AOSinith,GowserKecne,SouthWest,Other <br />IC.EAK DETECTOR Identification: <br />Red-Jacket Mod# 116-030, PLD 2see, Hex Head. Red-Jacket,Moda 116-01'7, DLD 2sec, Hex Head. <br />Red-Jacket.Mod#1 16-0 1 1A, OLD 5sec,Round Head. Tokheim,Mod$$5$5pM, DLD 2sec�SquareHead. <br />Tank <br />No�__1_ <br />Size <br />- <br />Produ�._l�Via <br />ub-pump <br />uf_�.� <br />LeakDetector <br />Identificatio <br />Serial <br />Numt*r _„ <br />3. <br />(,-oi 30 <br />® 0-0003 <br />14 <br />15I <br />16•� <br />17• <br />18. <br />I <br />19• <br />' <br />110. <br />1i. <br />112.113. <br />I <br />114. <br />116, <br />rr,,Ia�,J oas5 <br />Print: Certified Testers Name Certification Number <br />Certified Testers Signature Certif. Expiration Date Form:LD TEST 6190 <br />'PE "A <br />ES <br />••«• •• TANKNOLOGY CORPORATION INTERNATIONAL <br />4980-F Allison Parkway 9 Vacaville, CA 95688 • (707) 446.2494 • (800) 826.5837 • FAX (707) 446.2495 <br />