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DATA CHART <br /> For Use With <br /> petro Tlf4 <br /> I - IQN ESr a <br /> 1 LOCATION : I� I `-- ' rn � 1 `- 71-11(�Iy 1( � J� ci I � �C�) CF)„fir ' <br /> E Street No, and/or Corner City State Telephone No. <br /> z <br /> 3 � �CU <br /> O 2 OWNER : . <br /> Name Address Representative Position Telephone No. <br /> 3 OPERATOR : <br /> Name r� I- Doelo-r, Mgr, or Otho ; Address ( If different than Location ) Telephone No. <br /> 4 REASON FOR TEST . , IC <br /> � 'E � �1�_ �, C MZI oe�t `}- ° <br /> z �^ ( � <br /> o IJ <br /> t = t= 6 TEST REQUESTED BY : <br /> JAW O a u Name Position Order No. Billing Address <br /> O �(-- <br /> J 6 SPECIAL INSTRUCTIONS : <br /> 7 CONTRACTOR OR COMPANY MAKING TEST � / � l <br /> MECHANIC ( S ) NAME Y <br /> 8 ISA TANK TEST TO BE YES 9 MAKE AND TYPE OF � �-� - <br /> o � <br /> Ln MADE WITH THIS LINE TEST ? PUMP OR DISPENSERS <br /> © o m Qt= F] NO <br /> i of '� �•-� � COVER APPROXIMATE <br /> 10 WEATHER TEMPERATURE IN TANKS GES ' C OVER LINES L BURIAL DEPTH <br /> Con rete, Black op, etc. <br /> 14 PRESSURE 16 VOLUME 16 TEST RESULTS <br /> i1 IDENTIFY 13 LOG OF TEST PROCEDURES, <br /> EACH LINE ( TIME13 <br /> AMBIENT TEMPERATURE, psi OR kPa READING NET <br /> AS TESTED ( ) WEATHER , ETC, BEFORE AFTER BEFORE AFTER CHANGE CONCLUSIONS, REPAIRS AND COMMENTS <br /> Nth I `� 4S Ltko-lU <br /> Up <br /> CP�Nt ( D + <br /> c)7 <br /> - c�o�c� <br /> (D U7 001cu <br /> C�35LED iNZOI W2 <br /> `�' IbuU 10�1�U -tU01 <br /> caC� <br /> Cf � � Ez' b moi-' bL 26 C) Q + CW <br /> y <br />