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DATA CHART <br /> For Use With <br /> 1 LOCATION: A4'� I v O 1� �^ f-r ( ' <br /> i a' <br /> w Irerrt No.and/or Como CItY <br /> z <br /> _ State Telephone No. <br /> p 2 OWNER: <br /> l{ N�rnq Address Representative <br /> \� �{ Position TNrrPhonrr No. <br /> 3 OPERATOR: 1 <br /> 'Name Durr,Mpr.or Other Address(11 dill Want than Location) <br /> Telephone No. <br /> 4 REASON FOR TEST <br /> 1 <br /> z <br /> Z - HFO 6 TEST gEOUESTED BY: f .t <br /> < �1 <br /> ` ,� +• u C erns Position Order No. BlPlnp Address <br /> V, J6 SPECIAL INSTRUCTIONS: J <br /> 7 CONTRACTOR OR COMPANY MAKING TEST 1 <br /> MECHANIC(S) NAME C,C t1 (') �1 i , \CrCLO <br /> `J " 8 IS A TANK TEST TO BE YES 6 MAKE AND TYPE OF <br /> 1r) giw <br /> F W MADE WITH THIS LINE TEST? PUMP OR DISPENSERS 1 <br /> a o <~ NO c Y <br /> COVER <br /> 101,7/ 1 <br /> Y 10 WEATHER r��->>!L1 TEMPERATURE IN TANKS�;;L� 'F 'C OVER APPROXIMATE LINES t..f2'I <br /> BURIAL DEPTH L <br /> 11 IDENTIFY 13 L14 PRESSURE Concrete.Black Top,etc. <br /> MEOG OF TEST PROCEDURES, 16 VOLUME 16 TEST RESULTS <br /> EACH LINE 12 TIAMBIENT TEMPERATURE, <br /> AS TESTED (MILITARY) WEATHER, ETC. Psi OR kPa READING NET <br /> BEFORE AFTER BEFORE AFTER CHANGE CONCLUSIONS, REPAIRS AND COMMENTS <br /> 0290 <br /> 0 Z y Z OZ�o , 0260 vo 0 <br /> U � j r OLS Oz�a �, ObID <br /> 2 �Y <br /> 7 .,.. 3 1 16330 n-;,,ln <br />