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rl• '• (1iPETRO-CHECK INC. <br />2 OWNER: <br />Neare Address tl" Political <br />3 OPERATOR: <br />Name Dealer, Mor. or OtMr Address (if different than Location) <br />j <br />4 REASON FOR TEST _� ''U STOMP OLDT-12 <br />6 TEST REOUESTED BY: <br />Name Position Order No. <br />89ft Address <br />6 SPECIAL INSTRUCTIONS: <br />7 CONTRACTOR OR COMPANY MAKING TEST 9 <br />4,4 <br />MECHANIC(S) NAME <br />8 IS A TANK TEST TO BE <br />YES 8 MAKE AND TYPE OF - <br />PUMP OR DISPENSERS llb�W % VV4 <br />UtztM c% <br />MADE WITH THIS LINE TEST? <br />❑ NO <br />k" <br />COVER <br />TEMPERATURE TANKS 'F -C OVER LINES %OV <br />d)""-' r9 <br />APPROXIMATE <br />BURIAL DEPTH <br />10 WEATHER," <br />- <br />)N <br />Concrete. Bleck Too. aft. <br />14 PRESSURE <br />15 VOLUME <br />L) r) <br />11 IDENTIFY 12 TIME <br />EACH LINE <br />13 LOG Of TEST PROCEDURES, <br />AMBIENT TEMPERATURE, psi OR We <br />READING <br />NET <br />15ft ca <br />(MILITARY) <br />AS TESTED <br />WEATHER, ETC. <br />BEFORE <br />AFTER <br />BEFORE <br />AFTER <br />CHANGE <br />U „ � W <br />mss, g <br />eds <br />/wpe\ <br />l <br />epp� <br />kle-it r, to 4 <br />�.i ( oo <br />00 0 <br />0 <br />mmnm",_Imea� <br />