DERR-2024-012547

FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE SOLUTIONS
ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT

P.O. BOX 3360
DES MOINES, IA 50316

4140 E. 14TH STREET
DES MOINES, IA 50313
PHONE: [phone]
CORPORATE HEADQUARTERS

WWW.SENECACO.COM
STORE.SENECACO.COM
Seneca Account Rep:
Phone:
Date of Test:
Scope of Work:
Seneca Job #
Customer PO #
Technician:
Certification:(see test reports attached)
Testing Summary
Test Summary Description Component Tested Date Tested Result
Customer Information
Name:
Street Address:
City:
State:
Zip:
Contact:
Phone Number:
Site Information
Site Name:
Testing Summary
Street Address:
City:
State:
Zip:
Facility No.
Field Notes
4140 E. 14TH STREET
DES MOINES, IA 50313
PHONE: [phone]
CORPORATE HE

ADQUARTERS
P.O. BOX 3360
DES MOINES, IA 50316
WWW.SENECACO.COM
STORE.SENECACO.COM
Testing Summary
Testing Summary
FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE SOLUTIONS
ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT
FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE
SOLUTION ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT

Site Name: Site Address: -ob :
City: State: =ip: Date:
Scope of Work:
Arrival Time to Site: Departure Time from Site:
DP leak/Sump/SB Cathodic Protection MC/LLD Vapor Recovery Calibration
Technician: Post-Test SiJnature:
**By signing below, you confirm that the items listed above have been visually verified by you.
Site Contact: Post-Test SiJnature:
Inspector on site" Yes No If yes, please Jive name:
Service TestinJ
A.All
B.TestinJ
Yes No
Notes:
All shear valves have been set to open (if applicable).
TestinJ and Service Environmental Checklist
Dispatch Type:
4140 E. 14TH STREET
DES MOINES, IA 50313
PHONE: [phone]
CORPORATE HEADQUARTERS
P.O. BOX 3360
DES MOINES, IA 50316
WWW.SENECACO.COM
STORE.SENECACO.COM
Testers must upload a copy of this completed form with reports/photos and email to Mark Shirley and Emma Petrowitz.