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PLEASE PRINT <br />Data Chart for Tank System Tightness Test <br />DLkLYSIS NORTH <br />P.O. Box 95 • Bella Vista, CA . 96008 <br />(916)275-6667 <br />1. <br />OWNER e•vo.nrC <br />ran.... C <br />ErC ESI <br />2U IGl A) -/DU t�2 1/ ICTU Ie J'0 ( I CA. <br />f..rn. <br />2 OPERAT IR <br />OWN - <br />nvn. <br />3. REASON FCR <br />TEST <br />IEaolan Fwty) <br />Vez1 F '—TANs-ru- - 1 'ii..1E5S <br />4. <br />WHO REQUESTED <br />TEST AND WHEN <br />Tc + L <br />e }QST CONST. <br />"" <br />3633 Sa�lPoftT Sw «..,,Ybn '.. <br />7• w A ILAA+a-uratCA 900-675?76-!£ <br />S. <br />' <br />TANK INVOLVED <br />w .amtrf.r un.. <br />mr Inwipew nnu <br />le.neh h• Orr.mon <br />�(- NJILTFI <br />G+o.ntY <br />IOu��(�A�S <br />&rwSms« <br />Cr.a. <br />�It�SE1_ <br />bona. ,.q. <br />KrowJ <br />S,.r,Fypm <br />Z- SoyTN <br />JUU ALS <br />I <br />n Now,.:) <br />_ wE.ST- <br />ouU 6A <br />LA -J <br />__Uwa <br />ss<tZ <br />S. <br />INSTALLATIONt <br />DATA <br />I uon <br />�cg12 <br />wrn •nvo. anvwa.. <br />rl.Y tt iibOn. Y <br />CQVn <br />Coy cltc <br />Wrv«.. Sun rao, <br />�NN..1 <br />�Id <br />lrl <br />iu.. ^una m,... _nq <br />LO«. ?FMf. t.11. <br />p <br />ZI, N <br />jt1. lYr4bl.y <br />$SOrgM. <br />n otic <br />.M� :N. <br />PYnOf <br />(f2-&Vr . <br />#3 1'.u3ra: <br />an. arc:. <br />wVy. f .T.' <br />7. <br />UNDERGROUND <br />WATER <br />o.otn �e r. wa«nd. <br />^'GZbW I,1Nk5 f�L lAfl _v« _w <br />8. <br />FILL -UP <br />ARRANGEMENTS <br />�IYn. <br />F I..agq o:e-aaarvw vn:„.0 « o •q a a.• c ,«.logy.. <br />rY..nY ar aa« mono <br />lar none. ar rbvw <br />ca,nwm •..I.. -..orm, <br />9. <br />CONTRACTOR. <br />.MECHANICS. <br />�n.oww <br />10. <br />OTHER <br />INFORMATION <br />OR REMARKS <br />"� <br />Lire j =I - -T Ew 1'L - (ri i I ti G 5; tF - I _ + c L r n: LI 0 = CL - <br />,CYn(MY nlarmaran or. ,nr •I.m. ,oa... �Iticlra v :tow. � r 1Cv..q .n «nnq .a .n arr;r.v ar �^a�Y.e 'n n aea«nn a•.a..•r .ynn� es _._ <br />11. <br />TEST RESULTS <br />Tuts wa maAa on Ute above. tank ."t m In acmrmna Mttt two prooauro Pa*arn0.0 for <br />b t OW” a anac"d trt (nate YItt1 reutts m todl : <br />T,.n IC.nbfivlcn Tgnt Ur;. Inmcvtw Gn T.,vq <br />lom l oo P. 7-13 4 <br />�^ 12ht r2 tool , P,H. -/J -4 <br />3 4 <br />12. SENSOR 13. Trte a to a.nry ort oar sort ,ye.n,..�. b.f..q ort k+. (auto) r.vt.ti Ttea. iomaa s 'Ttgrtt nrw ttr attr� .feaofen.o <br />CERTIFICATION Nrdcnal Rre Prow don A.wtla0m Pwt hiol m <br />^� r <br />1�'_.o..a.. <br />cY• , < j S = L L R0 CP EYL S <br />DIALYSIS NORTH <br />s.n... P.O. Box 95 Bela vista. CA 96008 <br />ZST.�-rc 4 I c YO -/L7 Z <br />c«enutlo-t. o- <br />