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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OWNER/OPERATOR Gv.UTE/2T'�.z�5 <br /> RITE• ADDRESS <br /> �rq�J vTi e7�y/�C/ <br /> co1RTn <br /> NAILING ADDRESS <br /> 4!�/' <br /> SITE AGENT //��ypp�yy/��L1�pz_pe CUA— TELEPHONE �) d ��J�•'�!�/ <br /> ARRIVED TEST SITIC*VRDUNS TANK LOCATION �QjQr�iL ��ja•J' � PRODUCT <br /> DATE./TYNE SITMRACE FILLED 7 Z'O PRODUCT LEVEL AT ARRTTATIMINCIES BELOW TOT OF TILL NOMINAL TARE 917E <br /> TANK MATERIAL S•�L - <br /> �T o ArpROX. TANK ACF/Z--TRS. FILLSIzF,/TTTE�,OVERFILL CONTAINHIBNOT TYPE <br /> Afi GRAV1TT34_9 AT 70 DEC T. APi CR/lVI FY OF334 0 90F - COEFFICIENT OF EXPANSION OF _000 �� 7/� COE <br /> VISARLE VFTITINC ArrRPARS TO BE ATs ILL t8b FILL OPOSI7F, END, RAS SURF TIDE, HAS NALL CHECK, UNKNrnD1, OTHER <br /> VTSARIl VAPOR TRAPS TO BE SLED: BALL CHECKS, MARWAYS, RETURN LINES, OTHER <br /> ERASE II VAPOR RECOVERY "STE"! BALANCED, ASPIRATOR ASSISTED, IARC lum WELLS. MANIFOLD®, <br /> O OTHER <br /> POR'INC STSI'Q1t SUCTION, THRRiH MAKE ��TO T Wtmt. Ste' PIPE?LINE LRAX DeteCto'Ea) <br /> iP.S NO; NOT APPLiC <br /> CHARTED SIZE EST. LIRE QUANftri 7 PRODUCT ADDED To FLOOD SYSTEM J RTSTLM TONAL CAI.LONACF. 9'9 p o <br /> AMBIENT CONDITIONS! TEHrt PRETEST*LrOSTt9T f5� CLOUDY, SAININC, WINDY, PREF71', NICHT, OTHER c <br /> .4 rSI DROPI/0 HOURS TEST TO STAR7/1-3�1BOUSS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD TS[ <br /> A. CRAPE TO TARE BCrTOM /A� 7 <br /> oz3 B. rRAl1E TO TANK TIM <br /> 6•e,YAE I C. TANK DIAi1P,TY.R �y5 <br /> �• ���. —�{ If D. TEST IRVRL A" CRATM _c `2 <br /> • I B^z E. EXTERNAL GADIRID PATER APOVETANK �y <br /> F /�Q AfHTM IN. K .036elRl r51 <br /> /37 N r. Tor OF FILL TO PROD. AT ARRIVAL 3�o <br /> A-- C. MP Or FILL TO Ter OF TANK -36 <br /> TPTf-IRFEL TO NOTION Or TANK /OU <br /> PAHdR TN et <br /> C PSI PRO INCH or I'mu1Cf <br /> E TANK — / TEST HEIGHT PRLSSUP2 FORMULA <br /> 0-3/_ <br /> REMARKS: �'ac�e. �Gp ;• / j' �� N• PSI rsI RET-rs'T <br /> A l+.J� � �•'� <br /> RESULTS <br /> '1I�1. TFS'T PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS / GAGA o OF:Y� GALLONS PER HOUR, WITH A 997 CONFIDENCE LEVEL OFKf,II• <br /> �� <br /> THE HORNER EZ' CIIEK II t METHOD COTO'LIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 CPN <br /> FOR TANK INTECR I C. t ECT10N 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD, THE RESULTS <br /> SHOWN ABOVE: ES NOP INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br /> INTEGRITY TANK TESTING ICES,� 166 FRANK WEST CIRCLE, STOCKTON, CAA., 95206, (209) 466-8036 or (SOY) 262-8378 <br /> CERTIFIED TESTER [A1/I/'T/ STATE LICENSE 0 7 o-LU�� TEST DATE 7 Z Q / <br />