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S.0. <br />oNTfoR WELLS <br />Number 1 2 3 4 5 6 7 8 9 10 11 12 <br />Depth <br />Water <br />Prod.Detecte ° <br />NOT Detj <br />Location Ehagram <br />IParts and Labor used <br />MAR <br />General Comments u - <br />When local regulations require immediate reporting of a system leak -Complete the following: <br />Reported to: <br />Name Date Time <br />Phone Number Re File Number <br />RANDY G. ALDRIDGE <br />0321 <br />Print- Certified Testers Name TCi: #0062 Vacutect(tm) Certification Number <br />Certified Te tern Signature Date TextinR Completed Form:TestData 1/99 <br />