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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> (LANA LAYOU ON REVERSE SIDE) <br /> TE1;:IaG F/Z F/C DEN PDY.F0/F F_• :ARL: LDZL::Cr � % Tit`�P //% �y ��.'' C�c �i,�.t —i•'-at. .•�f+"•�--� <br /> ��� �� y- J <br /> L,.arLS .i�r� c= !`f/,L.�� �i..� _> >r�-Y �' ../..�/-CL_i�+�_� �c�ylyr--. •�G�' f_T+���21-:i/-t��c_ <br /> i�iF .e^�!/r� :11+�_f'/�+ � :/N- lc- %.�i•/7�.ca.1'�-G.� ~ !� e� AL�.+_� 1-���!�t�iG� <br /> :AFL tL?A:I. •/�� 'Gi PRODUCT. <br /> LIOt:r LLTL: CAL:s- . AMBIENT TEMP. PRETEST POSTEST <br /> �La <br /> PRIES: POSIES: TDP D7 i"..'. TC mO7 -.ARL /Q,v — <br /> / /� WATER PRESENT PRETEST + POSTEST <br /> ALS <br /> GiL�,5¢� T <br /> _ TOP Cl- FIL ro :07 O7 =ANT <br /> O7 - S __ INCHES ABOVE GRADE @ TEST START <br /> MOrEHLB o_0 <br /> _ __ TE'LPERATDLL eALiaw-Sows �f/ -� <br /> ATEY4:E I- A.P.I. 7RODUC: CRAr=T 41 @ _5-1 r - CRAr�Y �• x 4607 <br /> QUAR:I:Z ADDED LINT MOVEMENT -IQDID CONS:AF: (A) COEFFIC:ER: OF EIPASSION :AAI :i-'ACIZ TEHPERAIDRE COFSIAF: (E) <br /> L°VEL LEVEL GAIN+ TIMES LLr7ry TEMP. TEMP. GAIN+ 7I44ES TEMP. FIFAL <br /> TIME SART £ND LOSS- CON A AL54LT START END LOSS- CON B RESULT RESULTS <br /> �Zyl �z�l-oma-� 14, �E41 -�iyq� —,iz»- - <br /> i/3Ci 7-5- 1 /S 1 -4o I %3 . 625 <br /> 4e/7I -cam« /z.I/D <br /> S 7 1 ,;Z 1-,6;0I—= %3 �/7 16 /3 I-:eocl I -.e-,; 4 _ IlR , <br /> IZ2 I 1-37 I-S! I I- ,I z OZ- <br /> /35D4*11 <br /> 09 .603 1.,6,07 I-,0v/ I I-.cv�,69 -,z��y - 6 - <br /> 17, <br /> 1,35 - o ,��- I - :/3 �c 71 -��v:I =<z 14, �� I a� is yY� <br /> THE 'FINAL"HDUR OF <br /> REFLECTS A. LOSS/GE=E OF: LJtc .sf/G-C <br /> SITE ADDRESS <br /> MAILING ADDRESS <br /> / USING SHE HORN EA E2Y CHET. ME.. <br /> HOD OF PRECISIOF TESTING SHE RESULTS <br /> CITY 'c/ ARE W:TEIR / ARE ROT F'ITEIF THE SIATE OF CALIFORNIA AND THE NFPA <br /> 329 GUIDELINES OF A MA:-IMUY. LOSS OF .D5 GALLONS PER ONE HOUR OF <br /> COUNTY TESTING FOR A TIGHT :'ARE/SIS:"E8. <br /> TELEPHONE v ' INTEGRITY TANK TESTING SYSTEY.S, INC. 166 FRANK WEST CIRCLE <br /> ('{"� '� 1 — 7/ / STOCKTON, CA. 95206 (209) 466-8036 (800) 262-8378 <br /> AGENT <IZ�— �wL.! /bG -�If7�n CERTIFIED TESTER '.��y ��=����� TEST DATE <br />