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WORKSHEET FOR SUBMITTAL 7TO GOVERNMENTAL AGENCY � �/� II <br /> OGTIER/OPERAtOR d / r��Z� �'��[.� _SITE AbDRESS 6'w /f��~/e <br /> CITY COMITY <br /> HAILING AT)nRESS /�Q -© . �()� ���� � �7 Z-p <br /> SITE Ar.m. ltiCGL'.{� /LQ 4,4--e / Tr.T.EPHONF. <br /> ARRIVED TEST SI>i��NOTM TANK LOCATION/VA 4564i-1 A'OM lRODUCt—f r s� /it'c,'� <br /> DATE/TYNE STORAGE FILLED / �'" PRODUCT LEVEL AT ARRIVAL 4 INCRES REIOII TOr Or FILL }TOFIINAL TANK SIZE <br /> 7A71lC HATERIAL / y ArPR01L. TANK ARrf,4441{S, FTLLSI7.E/TTfF 7—OVERFILL tTMlrATWf"T TIFF. <br /> APT GRAVITT-4574- 1T ZDrc. F. - APT GRAVITY 01`37•2- 0 6Or COFFFTCIEM OF EltrARSTON Or ,000 _ COE <br /> VISANLE MITINC Arm-ARS TD RE ATI FILL T.TTD rut. OrOSTTE ETIO, NAS PUMP TITRE, tlAS PALL CHFCK, T1muloLIN, OTNT3t <br /> VISARLF VAPOR TRArS TO OF ALM PALL C11FCR5, "ANWATS, RETURN LINES, OTHER I <br /> rRA-SE 11 VArOR RECOVERY 91STFH! PALANCED, ASrIRATOR ASSISTED, LONG KIIT1 WE1,LS, MANIFOLDED NOIIF. 0711ER_ <br /> rumiNc STSTP3! 11CTi0N TURRINf. NAEE � ✓Cf HODFI. -7F!5-rlrt LINE LEJIR Detectots IFS, NO; OT Arr T <br /> CNARTFD SIZE 1&670 _ FST. LINT; 9"ANTITY / PRODUCT AnDED To rLOOT) STSTM5 STSTEII TORAL CAIA.MlArr. _ <br /> A"AIrM CONDITIONS, Tr}Irt rRETE9Ts(} rn'"r..3T 0L0UDT, RAINTNG, WINDY, RREF.7Ty ItIGRt, OTtt£R, -- <br /> Q rSt DR11a'90ROURS TFST TO START11r96lOURS PSI TO RE 14AINTAINr.D ON TANTO POTTM DURING TEST rFRTOT) 3,57 rsl <br /> R. CRAM TO TANT, ROiTOH .6 <br /> Idlo R. CRAT+F, TOTALAR 7br sj1Z- <br /> C. TAXI MA"A <br /> 6.P.f AE yTE <br /> 77 Ti;a'— D. TEST I.rVRL AROVE CRArM <br /> T?, 4x4RRtiL CRUt1lm RATP.R AROv$ TANK <br /> LL <br /> F— ! + 1 <br /> 2 ROTTOI l". 1 .(1161 "1 - 5� <br /> T. TOr Or rILL TO PO(M. AT AVOIVAt. <br /> r. Tnr or ritt TO TOr or TANK <br /> H. "TT"I.PTEL-Tib t4TTM CT TANV <br /> M <br /> rsl rRR INCU or rRnrg r <br /> WATER IN <br /> 1 TANK � TEST ME MIT TIMSURE FOIMA <br /> E <br /> /.3Sx ,trz�/ � 5 <br /> it, PSI r. rsi NFT r5l <br /> REMARKS! y <br /> ENMONMENTAL HEALTH <br /> 4��1�� <br /> RESUL'T'S r <br /> HIE, L TFT PERIOD AS SHOWN ON THP ATT'ACIIGT) CO111'unll GEkmATED DATA RrF1,rC*I'S A <br /> IHSS / Al OFT1{.00f CAI,LONS PrR TIOUR, WTTII A 997. CONFIDENCE LFVrL OF E/ cC7-2� P1,h, <br /> THE HORNER EZY CITEK II TES ETHOD COIIT'LIFS W1711 EFA AND T11E STATE OF CALIFORIfLA PERFORMANCE STANDARD OF 0.05 GF11 <br /> FOR TANK INTEGRITY-f'F-S .ECT ION 2643 CA.LTFORNIA CODE OF REGMATIONS) BASED UPON TIIIS STANDARD, 711E RESULTS <br /> SHOWN ABOVE,: DOES NOT INDICATE AN UNAUT ORI7_F,D RELEASE EQUAL TO OR GRF.ATER THAN THE 0.05 GFH STANDARD. <br /> INTEGRITY TANK TESTING SF VTCES, 166 FRANK WEST CIRCLE, STOCKTON, CA., '195206, (209) 466-8036 of (800) 26 -8378 <br /> CERTirrm TESTER STATE LICENSE I 9 V <br /> 0 -� f� TEST DATE, 4 <br />