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1 LIMITED WARRANTY Installation Form <br />Warranty Disclaimer: The DoubleTrac Limited Warranty is only valid if this form is received by the DoubleTrac Customer Service Team <br />within 30 days after installation is complete. <br />Contractor <br />Name <br />Address <br />Email <br />Phone <br />Fax <br />Distributor <br />Installer's State Certification No. <br />Installation Site <br />Name <br />Address <br />�.te <br />Completion <br />Installation <br />Date FEB� <br />Piping <br />Installer's Training Cert No.: E.NVI RON MENTAL HEALTH <br />DEPARTMENT <br />1. What size pipe was used? (Circle one) 1 " 1.5" 2" <br />2. Was any other underground piping used other than DoubleTrac? (Circle one) Yes No <br />If so, what kind? <br />3. What types of fuels are to be stored? (Circle all that apply) <br />Gasoline Gasohol Diesel Ethanol <br />Other <br />Please circle yes or no to the following. <br />4. Was the site contaminated before installation? <br />If yes: (a) Was the site fully remediated? <br />(b) Did the site receive clearance from <br />government authorities? <br />(c) What is the name of the environmental contractor? <br />Yes No <br />Yes No <br />Yes No <br />Methanol Fuel Oil Bio -diesel <br />5. Were all piping and fittings inspected for damage before and after installation? Yes No <br />6. Was approved backfill material used? Yes No <br />7. Was the Installation Manual followed? Yes No <br />8. Was any direct bury pipe crossed over? Yes No If so were crossover supports used? Yes No <br />9. Were all Self -Flaring Fittings tightened to spec? Yes No <br />10. Was the DoubleTrac Primary Pipe pressure tested? Yes No <br />11. Was the DoubleTrac Interstitial Space pressure tested? Yes No <br />12. Was Chase Pipe used? Yes No <br />13. Was the Secondary Jacket left open to atmosphere after testing? Yes No <br />Pipe Entry Points (please provide) <br />Name of Boot Manufacturer <br />All Boot part numbers <br />Circle yes or no: Was the exact size hole drilled for each entry boot? Yes No <br />Were all band clamps secured? Yes No Were the entry boot nuts properly tightened? <br />Dispenser Sumos (please provide) <br />Name of Dispenser Sump Manufacturer <br />All Dispenser Sump part numbers <br />Circle yes or no: Were sumps inspected for damage before and after installation? Yes No <br />Were the instructions followed? Yes No <br />Tank Sumps (please provide) <br />Name of Tank Sump Manufacturer <br />All Tank Sump part numbers <br />Contractor Signature Date <br />OmegaFlex® 451 Creamery Way • Exton PA 19341 • 800.355.1039 (Fax) 610.524.6484 - www.doubletrac.net <br />Page 11 <br />Yes No <br />DT -127 Rev. 05/08 <br />