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SQ# d w t-„� -�' Site# .2oV- -G 7 <br />�MONITOR WELLS <br />9 <br />Number, 1 4 8 10 11 12 <br />Depth 13 <br />• <br />NOT t <br />41a slkw'l <br />ataT "I <br />ttuN <br />a)c <br />�lsv� <br />V R S .2 -TU k4 r -s <br />!!Parts and Labor used <br />General Comments c-4 V,0.5 4-4-0 ,vv / �!-z w1 -r- X �-� s % z ii <br />OA/ %2-L4 -.J R,.h p s - S a 1- ,�� T a c-6 o --J <br />�i <br />�i <br />it <br />When local regulations require immediate reporting of a system leak -Complete the following: III <br />Reported •11 <br />Name Date Time 11 <br />Phone Number CUSTOMER or Regulatory Agency File Number <br />1� Z5 --j Y' 1) / <br />Print- Ce i ie Cera Name VacutectTM Certification Number <br />Certified T eters Signature Date Testing Completed Form-Tanks/Lines5/91 <br />