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C <br />DATA CHART <br />For Use With <br />/ �� <br />1 LOCATION- P � !V �i "r <br />I w Street No. and/or Corner City State - Telephone No. <br />ET: Z <br />z <br />C <br />I 0 2 OWNER: <br />Name �/ Address Representative Position Telephone No. <br />3 OPERATOR: u ) 1 <br />%j) Name er, 9r. or <br />Cther Address (It different than Location) Telephone No. <br />4 REASON FOR TEST _ ' `"® , (--4°�� <br />No. <br />LTJ <br />COVER,�,,// APPROXIMATE <br />OVER LINES 1�� `j' BURIAL DEPTH <br />Concrete, Black Top, etc. <br />M <br />11 IDENTIFY <br />EACH LINE <br />TESTED <br />12 TIME <br />(�,1ILITAR.Y) <br />( <br />z <br />14 PRESSURE <br />7 <br />16 TEST RESULTS <br />psi OR kPa <br />�0 <br />- t= <br />5 TEST REQUESTED BY: <br />CONCLUSIONS, REPAIRS AND COMMENTSAS <br />rn <br />AFTER <br />I w U <br />Name Position <br />o <br />J <br />ss ry <br />6 SPECIAL INSTRUCTIONS: <br />7 CONTRACTOR OR COMPANY MAKING <br />TESi'�---- <br />/2� ✓� <br />MECHANIC(S) NAME <br />8 IS A TANK TEST TO BE <br />— <br />❑ YES 9 MAKE AND TYPE OF <br />o <br />w � <br />r- w <br />MADE WITH THIS LINE TEST? <br />PUMP OR DIS?ENSERS _ <br />NO <br />< <br />d ~ <br />1 � <br />� o � <br />r ` C <br />10 WEATHER <br />11 <br />TEMPERATURE IN TANKS 'F 'C <br />No. <br />LTJ <br />COVER,�,,// APPROXIMATE <br />OVER LINES 1�� `j' BURIAL DEPTH <br />Concrete, Black Top, etc. <br />M <br />11 IDENTIFY <br />EACH LINE <br />TESTED <br />12 TIME <br />(�,1ILITAR.Y) <br />( <br />13 LCG OF TEST PROCEDURES, <br />4MBIENT TEMPERATURE, <br />WEATHER, ETC. <br />14 PRESSURE <br />15 VOLUME <br />16 TEST RESULTS <br />psi OR kPa <br />READING <br />BEFORE AFTER <br />NEI <br />CHANGE <br />CONCLUSIONS, REPAIRS AND COMMENTSAS <br />BEFORE <br />AFTER <br />O . <br />1 � <br />r ` C <br />'�!� <br />00 <br />4w <br />'T0 <br />0 <br />'n�z'b/'zwo <br />pkv <br />