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IDENTIFY <br />EACH LINE <br />AS TESTED <br />12 TIME <br />(MILITARY) <br />13 LOG OF TEST PROCEDURES, <br />AMBIENT TEMPERATURE, <br />WEATHER, ETC. <br />14 PRESSURE <br />z <br />ohm <br />16 TEST RESULTS <br />psi OR kPa <br />READING <br />BEFORE AFTER <br />NET <br />CHANGE <br />2 1 1992 <br />BEFORE <br />AFTER <br />DATA CHARTMAY <br />l�.rj <br />For Use With <br />ENVIRONMENTAL HEALTH <br />TEED �J l� <br />+ t V <br />I�LEEO P*K< <br />PERMIT/SERVICES <br />peetroT& <br />C1�,� <br />I�'J 1� I�l,itYiml�\� �-J 1 �f��Cll\` <br />`-, ' <br />CIc�J <br />w <br />1 LOCATION: <br />Sliest No. end/or Corner <br />CITY State <br />Telephone No. <br />E <br />Z <br />Z <br />3 <br />2 OWNER: <br />�b <br />O <br />Name Address <br />Representative <br />Position Telephone No. <br />—1-" <br />3 OPERATOR: <br />peeler, Mpr. or Other <br />Address (if dilgwnl than Location) <br />Telephone No. <br />LNem' <br />/� <br />4 REASON FOR TEST �LCZT L 2EQUi ZF—M ' \ <br />it <br />z <br />9 <br />0 <br />_6 <br />jA V <br />TEST REQUESTED BY; <br />Name Position <br />Order No. <br />Billing Address <br />y <br />O <br />J <br />'��� <br />+� <br />I <br />6 SPECIAL INSTRUCTIONS: Nin <br />I <br />�— <br />7 CONTRACTOR OR COMPANY MAKING TEST T <br />CO <br />-PON <br />In cclo w b =- Q <br />MECHANIC(S) NAME .Jb <br />V( <br />8 IS A TANK TEST TO BE ❑ YES 8 MAKE AND TYPE OF % �\ <br />LL <br />O <br />zjWN <br />r- <br />MADE WITH THIS LINE TESTI PUMP OR DISPENSERS <br />NO <br />mop <br />�p <br />�-?1 <br />COVER <br />APPROXIMATE !� <br />>.10 <br />t I <br />WEATHER /� L TEMPERATURE IN TANKS 'F 'C <br />OVER LINES C r- <br />BURIAL DEPTH ✓ <br />1C� <br />-.CC�IC� <br />Concrete. BI ck Top, els. <br />IDENTIFY <br />EACH LINE <br />AS TESTED <br />12 TIME <br />(MILITARY) <br />13 LOG OF TEST PROCEDURES, <br />AMBIENT TEMPERATURE, <br />WEATHER, ETC. <br />14 PRESSURE <br />15 VOLUME <br />16 TEST RESULTS <br />psi OR kPa <br />READING <br />BEFORE AFTER <br />NET <br />CHANGE <br />CONCLUSIONS, REPAIRS AND COMMENTS <br />BEFORE <br />AFTER <br />l�.rj <br />Colo l U <br />TEED �J l� <br />+ t V <br />I�LEEO P*K< <br />C1�,� <br />�3 <br />CIc�J <br />-.C70 <br />0(__�r_JD <br />I <br />�b <br />it <br />'��� <br />+� <br />I <br />_1 L_0 <br />I <br />LSC l <br />I <br />1C� <br />-.CC�IC� <br />1Ns <br />L� <br />,Ob <br />+--,Inh <br />