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12/01/2005 12:17 16613637474 CHAMPION PT INC PAGE 04 <br /> c 2.-9 L4 '72r <br /> CHAMPION PRECISION TESTING,INC. <br /> JOB ORDER&WORD REQUEST FORM <br /> Site Name: Nick 76 Address: 16500 S.Harlan J2 City, ro GA ' <br /> X Street: Site Phone: 209-478-9583 Site Contact:Nick <br /> Bili To. Address: P.O.Box 690514 Phone: <br /> Attention: Fax. <br /> Scope of Work Requested. <br /> [X]Monitor Certification [X]Spill Buckets [X]Leak Detectors <br /> [ ]Secondary Containment [ ]Tank Test [ ] Line Test <br /> [ ] Cathodic Protection [ ]TP201.3 Decay [ ]TP201.4 Blockage <br /> [ ]TP201.5 Air to Liquid (AIL) [ ]TP 201.313 AST Decay [ TP 201.18 Torque <br /> [ )TP 201.1 CID Drop Tube Integrity [ ]TP 201.6C I TP 201.6 [ ] Designated Operator <br /> [ ]Other <br /> Job 9:101405KH01 PO/Authorization#: <br /> Date of Test Tech Name Start Time End Time Travel Time Miles <br /> 10/14/05 Keith Huston 9:00 am <br /> Test Performed Price Quote Parts Used C Parts price <br /> o1 <br /> UST Permit# Air Permit# CUPA Air <br /> #Tanka: #Dispensers: Nozzles: Products: <br /> DW SW MFG: MFG/Model: 87 89 92 Die <br /> Other: <br /> Phase 2 Type: Phase 1 EVR: EM Type; #Spill Buckets <br /> Technician: Hel er; <br /> Test Day: Test DaI�... <br /> Comments:Any parts replace must be signed for by owned manager of Facility. <br /> Facility inspected by owner/managerlemployee verifying that everything Is as when arrived on site. <br /> Manager/lDhcaler Print Name Manager/Dealer Signature Date <br /> Scheduled by: Amy Vath ,� Date:October. 2005 <br />