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S Cust. Site# <br />MONITOR WELLS <br />Numbe 1 2 3 4 5 6 7 1 8 9 10 7 11 12 <br />Depth I I I <br />Water <br />Prod.Detecte <br />NOT Det <br />Location Diagram <br />Parts and Labor used <br />jjWhen local regulations require immediate reporting of a system leak -Complete the following: <br />Reported to: <br />Name Date Time <br />(I <br />u <br />�j Phone Number CUSTOMER or Regulatory Agency File Number <br />Print: Certified Testers Name VacutectTM Certification Number <br />Certified Testers Signature <br />Date Testing Completed Form -Tan ks/Lines5/91 <br />