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Mr�l I \C111(HW`+1 I:l'I( F <br />IMA -0 T <br />P9"90LEUrn-,-E(WfPTfiEN f- .93XFORM 93701 <br />Owner/Operator : 4/ <br />City, St., zip : 711 <br />Site Agent <br />Site Addresses <br />County <br />Telephone' No.: <br />Line Connected to Tank Number/Location <br />Product Line Dispenses : % Approximate Line. Length (in Feet) e2 <br />Line Material Line Has P.L.L.O, es / No <br />Turbine Make %Moder Dispenser Make / Model <br />Tank -Test' Equipment to be in Place During Line- Test: Yes / o <br />Line -to be Tested With a Line -Block' in Place of P.L.L.D. Ces o <br />Turbine Output Pressure P.S.r: Test.Pressure to be c P.S.I. <br />Time Initial Final Yoitmie Leak Average <br />Pressure < <br />Pressure Displaced Rate Leak Rate <br />Using the Campo/Miller PL -400 Pressurized Piping Tightness Testing Equipment and test methods <br />the results as show ow not allow the line to be considered product tight. <br />Final Results G.P.H. <br />Tester_, License Wo. <br />Test Date,: y <br />Tes'ter's Signature <br />LPEI= <br />• :u�(L::iF�m:s; FUCtcprw :,T•+irSwG �+< <br />. :•Eta::SiOir.�'+=::wi; O�iipaESSJr. ^.:iJ.tA4.Ki..o.Su5tK1< .. - _ -�� <br />• $tEa:, ,; fkpe m••r `lfil p(XiinS • �c:r:yii S(R:•Jsv+�011USSaurtti �`>i5 cao04 cCCCv(4t c '�. _:i:Eduu4.(4:�Otnrt:a..; :!: ri: <br />- • SS�F wticn:.; ..•fit 00. T .S •� - ( ua....^ .. •:i : .. <br />iw:!c .NArNi .c ."7. ELWii/K: _ au i:::r.y 4K.D C. •-�.! EA.', .. ,wae.N.. <br />