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--Data Chart for Tank System T"ghtness Test <br /> PLEASE PRINT <br /> 1. OWNER P p"El <br /> Tanana)El Name__--. Adww Rprrantwwe TMeplwne <br /> 2. OPERATOR ------ _. <br /> Name Addap TNepnpM <br /> 3. REASON FOR <br /> TEST _ <br /> IErpl..F0, --- -"'-"- <br /> 4. WHO REQUESTED <br /> TEST AND WHEN Name Tab cpmp+nY or Affiliation Date <br /> A". iahpnwp <br /> Idenhh•by Nl tlon cv..4 8mm'Suppllr Dreg Apwoa.Ape SYeM:F:brpWa <br /> 5. TANK INVOLVED <br /> Law•adnienN line -- <br /> tw menlfolded 1Apb <br /> loctllon Cour flub Wmb 9lpnpnr pampa <br /> 6. INSTALLATION (� _ k� <br /> DATA <br /> wdn.aide driveway. C.ncnata,'Jwa Top. Slae.T1btIN mbb.Drop Sw-cion.Remob, <br /> Neu of atphpn, to E".al, h�br.RdmoN FlNa 'Y,W loo a WTItlI tache? Mahe N known <br /> ]. UNDERGROUND b the•aetr ovr lM,v,it? <br /> WATER Ixpd,to me Waw able I1 F'LOW TI'��1/Jr . — ❑Yr <br /> 8. FILL-UP Tarn.to be hued M. Dne An+upW by <br /> Name Telaptwn+ <br /> ARRANGEMENTS Erre product W•mp OW and mn unit leave. ww u,d wind to p:madat Conalder No teed. <br /> TamNng w cmw cdotwe -- --- <br /> br o i.w Irpu:ry _ i <br /> Crnperry Twwmone <br /> S. CONTRACTOR, -- —__ <br /> MECHANICS, <br /> any otnr contbctw <br /> __ PER.MIT i ccr„f;, fLTH <br /> 10. OTHER - --_— <br /> INFORMATION <br /> OR REMARKS <br /> fEdNionat Nlamwbn w�any ibme abpre.OMIU W w mnen b M ebbed wnen aMbp Y it prprepa or cpmplab0.Neifob w oeerven preard dudnp tzt eb <br /> Teds?req maAa m lM eh WN INI fyalwna it,a=rAanb wIM led prayeadi a preet]1p0A f r <br /> 11. TEST RESULTS r ddeMU oR dleched'.eet cn,arb with reeulb,a f0trarm: <br /> Te•n dendpcatlm n�nt Laai:ape�nd:cxed _ Dme T•wted <br /> 12. SENSOR 13.Thi.4 to reTtlfy iMt Mleea fntlt eyebtne waro.+dey a tlaN t1NIN(a)dlEwe Tttpae IntlpataA r'ryi+P.tad iRe v!+rue+aex+r:+wa'w ver <br /> CERTIFICATION 'Dr'%�d/F P�w "�/A��w('N/�//Al/A,n PwDT•"a Y19 <br /> G ,oaweae � Pos <br /> ��I��Ml�K� Sbnaere— _ <br /> t Office Box 568 <br /> ---- - Stockton,L.A 9!)204dww+ ------ — <br /> G:urcrhone __ <br />