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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OWNER/OPERATOR lZ`pVZD5— 1G']� <br /> Y SITE ADDAESE <br /> CITY rc c ' l ' ��SCOUNTY SfliL' C.cl�s'Li%c� <br /> MAILING ADDRESS <br /> SITE AGENT �J C'f�2.- �/-j�-`--/L TELEPHONE <br /> ARRIVED TEST 3228^&'rg0Ug5 TANK 7gGTI0N lvllktl( <br /> PRODUCT <br /> DATE/TIME STORAGE FIL,GLE7-D / 7 4 C'fPRODUCT LEVEL AT ARJRIVAL a IRCHES BELOW TOP OF FILL NOMINAL TANK SIZE ZCQei <br /> TANK MATERIALAPPROX' TANK AOp�T IRS. FILLSIZE/TTPE Q OVERFILL CONTAINMENT TYPE <br /> API GRAVITY 3 ZeAT T' 5 DEC. F. - API GRAVITY OF3_L B 6OF - COEFFICIENT OF EXPANSION OF .000 �l Z - <br /> � cae 7_Z <br /> VISABLE VENTING APPREARS TO BE AT, FILL Elm, ALL OPOSITE „ HAS BURP TUBE, RAS BALL CHECK, <br /> UNKNOWN, OTHER <br /> VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, MANWAYS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY SYSTEM: BALANCED. ASPIRATOR ASSISTED, LANG RUN GWnLS, MANIFOLDED, NONE, OTHER <br /> PIMPING SYSTEM: UCSION TTIRH INE MAKE/-7� ��"'7� MODEI 70 6 PIPE LINE Lux Detectors YES, _ <br /> //JJ NO; OT APPCIC <br /> CHARTED SIZE L'� EST. LINE,QUANTITY 3 PRODUCT ADDED TO FLOOD SYSTEM TSYSTEH TONAL GALLONAGE <br /> AMBIENT CONDITIONS: 2Y18: PRE7'[SYTL- POOS�TTEST SUNNY, CLOUDY, RAINING, WINDY, BREEZY, NIGHT, OTHER —e- Y <br /> .4 PSI OROR'%7ROURS TEST TO STAAaf'Z61:• HOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD y-1 4�/ PSI <br /> A. GRADE TO TANK BOTTOM <br /> R. GRADE TO TANK TOP <br /> 6411 pF <br /> C. TANK DIAMETER T"-7 <br /> -~ D. TEST LEVEL ABOVE GRADE 3 �_ <br /> 1 8•---- E. EXTERNAL GMLWM RATER ABOVE TANK <br /> Bo ra" IN. K .0761 PSI <br /> N �-O F. TOP OF FILL TO PEW. AT ARKIVAL <br /> A G. TOP OF FILL TO TOP OF TANK _ 45 <br /> H. Tm7j2m,TU 70801 OR TANK <br /> RATlR DE C PBI PER INCH OF ►IDDUCr <br /> E TALAR .. - TEST HEIGHT PRESSURE FORMULA <br /> Ke-q/ _ <br /> REMARKS: H. PSI E. PSI MET PSI <br /> RESULTS <br /> THE AL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS / AI OF: �1GALLONS PER HOUR, WITH A 99_% CONFIDENCE LEVEL OF +/— .00(D gPh, <br /> THE HORNER EZY CH OD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEG}X TF TE NO. SECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br /> SHOWN ABOVE: L�E$ 083 HOT INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br /> INTEGRITY TANK TESTIN TICES, P.O.BOX 6913T6 STOCKTON, CALIFORNIA, 95269 (209) 474_1375 or (1,00) 2 2.-8378 <br /> i <br /> CERTIFIED TESTER G r w(/ <br /> ! `� STATE LICENSE M q(, i/ TEST DATE <br /> /,M6/1 D <br />