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i <br />CONFIDENTI.A.L <br />Praxair Services, Inc. <br />Technical Solutions for the Industrial Mirid. <br />C� <br />UOISCO i1 Tr-mderI;eaeV#-ah C:orrocon <br />Site Infbrmatron For Enhanced leak Detection Sires <br />Submit Completed Form With Each Jobl <br />Technician?"L,L VA C,(,- Job ;V_1617y y Li L4 Date I Z-4('4Cl <br />Site Nam <br />EPurpose of test: (Product on water table? Within 1000' of well? Untes"le secondary aonlninment? <br />tuergehcy Gc"mutnr? Cansaltaat nmommtndaou? ate). Regulatory directive: New Installation'1 <br />Spill Bucket Test TKj!P atl) M � Tg a=/F <br />Type of Sumo Pu mn (Suction) rbine TICS t ss/Fad) M (Pass/Fail) <br />Vent Line Probes --pig t e <br />Vapor Recovery line Probes Tu'_ S r46JE PS (ft 'Prri vo, <br />Types of Bacldill <br />Tank Pito t'd <br />Ground Cova concrete Asphal (other) <br />Ground Cover Condition (Excellent) o d (Fair) (Poor) (other) <br />L_ rat All Component Types <br />Tank (Single Wall) le W (Steel) `(F erglas (other) <br />Lines (Single Wall) oub7e ) (Steel) t r :. "" (Fibertrench <br />(other) <br />Vent Lines (Single Wall) ,able W (Stec <br />n....7ib!Lgl!a(other) <br />Vapor Recove ry (Single Wall) (Doable W ) (Steel) fiberlas(other) <br />Va orRecoV ~-^� 4, <br />P ery (Balance) <br />Sumo Construction: (Sealed to tank top) (Dirt) (Retrofit— bolted to riser at tank to trofit b <br />= <br />Snill Rnrlret PI,, e. a ._ ':?l � c P) .,..._u. 1 <br />Tank Manifolds bel{'•) <br />Monitorin Well(Locations and depths) 9C�1 <br />Water in Sump: YES / b Depth from surface: <br />Water in Line trench: YES A15 Depth from surface: <br />Water in tank pit: YES / l0 Depth from surface: <br />Zine Le k Detectors \/ t k Lt>-?Jn® <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 />