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L <br />C <br />DATA CHART DIALYSIS NORTH <br />For Use With ENVIRONMENT HEALTH P.O. Box 95 <br />Petro 'rite Line Tester PERMIT/SERVICES Belle Vista, CA 96008 <br />r, Ti(530) 275-6667 <br />1. LOCATION: l'cywGr T /So/ N. Tic/ -C To�UC E PiPoA/ CA g5-3GG 209—S99—`/l`0 <br />bir r LWOW Svw aum I ampnune. <br />2. OWNER: <br />me AMOSS Keprewnmm Posmon lullpfione <br />3. OPERATOR: <br />ame ulaw, m9r, or uner AaaM (ff MRR Nh MMon3ep one <br />4. REASON FOR TEST: 41t/AMgr TEST/N 4- <br />9gP1 yoerc-7HCr� t�2►ve- ,ag <br />5. TEST REQUESTED BY: (4 em ('.t em(cA1TS N7C e� W® lo3 N.RuYra�Tyr> tad, 4yt33 <br />6. SPECIAL INSTRUCTIONS: <br />7. CONTRACTOR OR COMPANY MAKING TEST 1 <br />MECHANICS) NAME: /Jl'��YfiS Ald <br />8. ISA TANK TEST TO BE ❑ YES <br />MADE WITH THIS LINE TEST? 0 <br />10, WEATHER GL&rAR Afid'HT TEMPERATURE IN TANKS <br />Crg <br />9. MAKE AND TYPE OF <br />PUMP OR DISPENSERS: RL') TRCKC7— <br />o3 -1Coo <br />COVER APPROXIMATE <br />OF °C OVER LINES 00 L•Ac i a' BURIAL DEPTH <br />1,0n r°TsP, eW.- <br />11. 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 <br />W <br />-3z <br />NET <br />CHANGE <br />CONCLUSIONS, REPAIRS <br />AND COMMENTS <br />o <br />Z <br />A <br />KeAucc Pr) <br />ACLUSn/ - L/AJr /0lq5S6Ti <br />/ <br />/JLt��`)��f� �K D ./�. <br />W <br />7 "z viJ <br />`S ; % O <br />f TA /r-7' L r ^) c- TtT-,' <br />O <br />z <br />a <br />Accra Si <br />S :y3 <br />Nc 7tx7— <br />CL <br />�J <br />J <br />.05G <br />—, ooz o <br />p :oo <br />L,•.J 71 <br />'5"9 <br />D <br />US60 <br />,DIVS <br />', &90)$ <br />u - <br />60 <br />, 05-Yf <br />, 05-30 <br />- 001 S <br />UG -30 <br />DATA CHART DIALYSIS NORTH <br />For Use With ENVIRONMENT HEALTH P.O. Box 95 <br />Petro 'rite Line Tester PERMIT/SERVICES Belle Vista, CA 96008 <br />r, Ti(530) 275-6667 <br />1. LOCATION: l'cywGr T /So/ N. Tic/ -C To�UC E PiPoA/ CA g5-3GG 209—S99—`/l`0 <br />bir r LWOW Svw aum I ampnune. <br />2. OWNER: <br />me AMOSS Keprewnmm Posmon lullpfione <br />3. OPERATOR: <br />ame ulaw, m9r, or uner AaaM (ff MRR Nh MMon3ep one <br />4. REASON FOR TEST: 41t/AMgr TEST/N 4- <br />9gP1 yoerc-7HCr� t�2►ve- ,ag <br />5. TEST REQUESTED BY: (4 em ('.t em(cA1TS N7C e� W® lo3 N.RuYra�Tyr> tad, 4yt33 <br />6. SPECIAL INSTRUCTIONS: <br />7. CONTRACTOR OR COMPANY MAKING TEST 1 <br />MECHANICS) NAME: /Jl'��YfiS Ald <br />8. ISA TANK TEST TO BE ❑ YES <br />MADE WITH THIS LINE TEST? 0 <br />10, WEATHER GL&rAR Afid'HT TEMPERATURE IN TANKS <br />Crg <br />9. MAKE AND TYPE OF <br />PUMP OR DISPENSERS: RL') TRCKC7— <br />o3 -1Coo <br />COVER APPROXIMATE <br />OF °C OVER LINES 00 L•Ac i a' BURIAL DEPTH <br />1,0n r°TsP, eW.- <br />11. 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 <br />K s <br />READING <br />BEFORE AFTER <br />NET <br />CHANGE <br />CONCLUSIONS, REPAIRS <br />AND COMMENTS <br />BEFORE <br />AFTER <br />KeAucc Pr) <br />ACLUSn/ - L/AJr /0lq5S6Ti <br />/ <br />/JLt��`)��f� �K D ./�. <br />7 "z viJ <br />`S ; % O <br />f TA /r-7' L r ^) c- TtT-,' <br />O <br />--^-- <br />9j90 <br />Accra Si <br />S :y3 <br />Nc 7tx7— <br />S3 <br />�J <br />, D.Sbo <br />.05G <br />—, ooz o <br />p :oo <br />L,•.J 71 <br />'5"9 <br />D <br />US60 <br />,DIVS <br />', &90)$ <br />oG �/ S <br />60 <br />, 05-Yf <br />, 05-30 <br />- 001 S <br />UG -30 <br />L/tilEr T - <br />c <br />0 <br />'0530 <br />, 0515 <br />; 0,0 1-r <br />�: <br />®✓ �� S <br />3L�n) C (°UIGrP,C <br />�O J <br />a <br />, v -sl S <br />. /3d'o <br />f ®�G� <br />M _ 0 See Next Page <br />