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CONTRACTOR/ENGINEER <br />SITE NAME <br />ADDRESS <br />Compliance <br />Repair/Construction <br />Insurance <br />Escrow <br />Make & Type of Pump or Dispenser <br />Y ` �4 VO 6 C / 1.4 `0 44.-� <br />Cover Over Lines <br />CC) ocre <br />Approx Burial Depthi <br />,y %c�w� <br />{ <br />o1490 - <br />Suction I Rl nr.q TAMOZ to, MoInir_ nc vein um u.no <br />&-r �� 416 2nd Street Gait CA 95632 LINE & LEAK DETECTOR <br />ri ,(209) 7{ (20 9)7"-0116 FAX;: <br />REPORTTEST <br />LOCATION SKETCH <br />TEST DATE /;I— --' 14 — -` <br />PHONE <br />ow <br />Calibrated to 3gph @ 10 psi <br />FTA LEAK DETECTOR TEST INFORMATION Calibrate <br />10 PSI <br />LEAK DETECTOR KEY <br />Disp#/ <br />LD <br />Opening <br />Time <br />Leak <br />Rate <br />Functional <br />Element <br />Metering <br />Product <br />Key <br />Serial Number <br />Resiliency <br />In Seconds <br />Mullin <br />Holding Psi <br />PSI <br />Pass / Fail <br />A <br />LD 2000 <br />P / F' <br />B <br />LD 2000 E <br />P / F <br />C <br />FXi V <br />P / F <br />D <br />FXI DV <br />P / F <br />E <br />STPMLD <br />P / F <br />F <br />STPMLD - D <br />P / F <br />G <br />STPMLD - E <br />P / F <br />H <br />STPMLD - D/E <br />Notes: <br />CONTRACTOR <br />LINE TEST RESULTS <br />CERTIFICATION <br />Tests were made on the line systems as noted in accordance with test procedures <br />Technicia L l D. Nimmo <br />prescribed for as detailed on the test chart on Side 2 of this form with results as -follows: <br />LINE IDENTIFICATION NET <br />VOLUME CHANGE PER HOUR <br />PET-ROTITE CERT# <br />1�/ <br />PAS / FAIL / INCONCLUSIVE <br />, 104 67 <br />090993AO163 <br />PASS / FAIL / INCONCLUSIVE <br />OTTL Lic# 97-1143 <br />Trainee: <br />PASS / FAIL / INCONCLUSIVE <br />PASS / FAIL / INCONCLUSIVE <br />EQUIPMENT: PETRO TITE LINE TESTER <br />