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L <br /> WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> �f �} <br /> O+NER/OPERATOR Z73 �.1? S� J1/ Y <br /> SITE ADDRESS <br /> LIP \ IRS COUNTY, <br /> MAILING ADDRESS <br /> SIZC ACe1tT ��yyyc�vr� SCJ (K�),V,J ✓ TELEPHONE ( ) /Jyy,�yfd`�j -- <br /> ARRIVED TEST SI7MOFIGURS TANK LOCATION 'fIf I�SI�T_ PRODUCE 4t*4: T iCr3« <br /> DATE/TDa STORAGE FIL PRODUCT LEM AT AAMTALBELOWW UM <br /> 1NCRES BOW TOF FILL RUMINAL TANK STIS �.�� <br /> TANK MATERIAL ` APPROX. TANK AGDF r T8577. FIILLLSIZE/TTPE It OVERFILL CONTAImmIc" TTP_ A <br /> API GRAVITY X-7AT SSDEG. F. a API GRAVITY OF: •T F 60F a COEFFICIENT OF EIIPARSION OF .000 4 <br /> - COE S,F <br /> VISABLE VENTING APPRPARS TO BE ATT FILL END. ELL OPOSITE <br /> RAS BURP YUEE, RAS 7LALL CHECK, ONKI1gWN, OIRF1 <br /> VISABLE VAPOR TRAPS TO BE BLED: FALL CHECKS, KUWAYS, RETURN LINES, OTHER <br /> PHASE II vAI`OR RECOVERY SYSTEM: HALING®, ASPIRATOR ASS_STED, LONG RUN WELLS,-" MUNIFOLOED, <M OTHER <br /> PUMP INC St STEN: CTIOq TURD INE MAKE--41 E MODEL??��PM LINE LEAK Detectors YES, NO, T A-'PLT <br /> CHARTED SIZEJ(Vl!� EST. LINE QUANTITY 7 PRODUCT Ap)CDYD S�TD FLOOD STSIu[ STSTEN PORAL CALLONACE ZOZ/ <br /> AMBIENT CONDITIyON�St TETiPt PRETLST�POSYE57 6UNNE�CLUIDT✓J RAINING, WINDY, BREM, NIGHT, OTHER <br /> .6 PS1 DRtlA/NOUAS TEST TO STAR/ZROURS .PSI To BE MAINTAINED ON TANK BOTIM DURING TEST PERIOD <br /> B 753 <br /> A. GRADE To Tim BOTTOM f 6 <br /> B. GRADE TO TANK TOP <br /> 6•u.OF C. TAMA DIAMETER ..�_ <br /> ..•7PTTm�—' D. TEST LEVEL ABOVE OMD[ -77 <br /> •`• le- [ J ems— H. EAEOR.V. DAOGW WATER ABOVE TA= <br /> C) F— L/ wrrcm IN, 1 •0161 PSI . <br /> 196 <br /> F. TOP Of FILL TO PAW. AT ARRIVAL 0�J <br /> C. TOP OF FILL TO TOP OF TARE 4!r <br /> 4�1 H. TErr-AmmTir)DITCH OF TMR1_ <br /> WATER 1 OE C PSI FEE, No OF pwwa � <br /> E TANK • • TEST N1N1119010PRESSURE PO"VLA �T <br /> K a$ 4./7 <br /> REMARKS: <br /> N. ►SI E. FSI NET PSI <br /> • <br /> RESULTS <br /> THE OD L TEST PERIAS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS / CA Of`t-� GALLONS PER HOUR, WITH A 992 CONFIDENCE LEVEL OF +/- 000/ gph. <br /> TEE HORNER BLL C8 MICTION <br /> VYSB 8FA ASD SIE STATE OP C�LSRTANIA P88FOR1GRC8 STANDARD 07-O.OS GPs <br /> POS TANK into STIN MICTION 2607 CALIPOANIA CODE OF REGULATIONS) BASED UPON TSIS STANDARD THE RESULT <br /> S80Yy OV -T !1 y. .4 11-3438 EQUAL TO ON.OAWNE T8At.TEt O.OS OFB itANDAAD. <br /> 4 VAAUT3082E80 B <br /> w—` Ct3 <br /> STATE_LjC38$B._F. Tut AAT1- <br />