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Confidential <br /> Praxair Services, Inc. <br /> Technical Solutions for the Industrial World <br /> Site Information For Enhanced Leak Detection Sites <br /> Submit Completed Form With Each Jobl <br /> Technicien� <br /> inn 01iPiCC. <br /> Job p $6o431 Dete 16J- 02' 't7y <br /> Site Name Vin]\'Ica 1 t' l o r G.1.19—`4-g <br /> Purnoae of test:(Product on water fable? Within 1000'of well? Untestable secondary cpntainmenl7 Regulatory directive? New Installation? Emergency <br /> GenerstmR Consultant recommendation other): <br /> CUPA(regulatory Mine): <br /> : <br /> Spill Bucket Test: TKI Fail) TK2 as ail) TK3 U oasail) TM (PUS/FSil) TK5 (Pass/Fail) TK6 (Pass/Fail) <br /> Type of Sumo Pump (Suction) me RJ <br /> Vent Line Probes <br /> Ve or Recovery Lme Probes - <br /> Types of Backfill <br /> Tank Pit <br /> Line-Trench _ <br /> Ground Cover Concre P (other) <br /> Ground Cover Condition (Excellent) Good (Fair) (Poor) (other) <br /> List All Component Tynea <br /> Tank- (Single Wall) ouble Wall (Steel) ib 1 (other) <br /> Lines (Single Wall) ouble Wall (Steel) fiber lass (Fibertrench) (other) <br /> Vent lanes (Single Wall) UNMEEgo (Steel) fiber las (other) <br /> Vapor Recovery(Single Wall) ouble (Steel) Fs erg as (other) <br /> Vapor Recovery stance (Assist) <br /> ofit—boltedtoriaerattmktop) (Retrofit—bolted to runaway)Sumo Construchon: (Sealed to tank top) (Dirt) (Retr <br /> 1. ATG riser contained in a sump YES / <br /> 2. Annulus contained in a sump YES / <br /> 9 <br /> 3. Fill riser contained in a sump YES I e <br /> 4.Vapor riser contained in a Sump- YES I%0 ' <br /> 5. Turbine contained in s Sump YES I NO <br /> 6.Other risers 'ES / NO <br /> Spill Bucket Pluneef T e etc. <br /> Overfill Protection Al t <br /> Is <br /> Tank Fills <br /> M f la <br /> Mo i orin Wel aggations and depth _ <br /> Water in Sump: YES I NO Depth from surface: <br /> Water in Line trench: YES I No Depth from surfsce: <br /> Water in tank pit YES N Depth from surface: <br /> 4 <br /> Line Leak elec ors <br /> Fibertrench description: <br /> Composition: <br /> Shape(draw picture if necessary): <br /> Depth to top: <br /> Signature of site person verifying condition of site at end of installation: <br /> �� CA licensee — �� <br />