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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OTINER/oPEMTOR__ <br /> CITY LQ Q� /' , 91TE ADDRESS,.y(�il/YL-. <br /> T7--• C.-/Y COID7tt �ir'v�l�J�a C/l•C� <br /> MAILING ADDRESS �ff <br /> `lel A ✓O C.9. 9�69� <br /> 517E AGENT <br /> Sid g TELEPHONE (��) �JZ- AZ 77 may' <br /> ARRIVED TEST SIT®74re-lo TANK LOCATION <br /> PRODUCT •D/GSA.�vFL. /L�Ld�"' <br /> DATE/TINE STORAGE FILLED l0� PRODUCT LEVEL A,Tt-ARRIVALO INCHES at To?TOP OF FILL NOlfIHAL TANK SIZE <br /> TANK MAtERIAL APPROK. TANK ADN+ 7 '------ <br /> ,�IF TRS. FILLSII.E/TTrE_�_OVERFILL CONTAINMENT 7�•F_'fjp yL` <br /> Aft CRIIVItT?Q'7' AT �/ DEC. F. . Ari GRAVITY OFjZ. <br /> 0 60F - COEFFICIENT OF EXPANSION OF .000 4SQ(pp ` <br /> V1SAgLt VENTING APrR" TO BE AT V COC QS,J <br /> FILL [1>fl FILL OrDSIIE1EpD, pA5 BVRP TUBE, HAS BALL CHECK, DM MI, <br /> VISABLC VAPOR 1llAT3 TO BE PLED! OTUFJt <br /> BALL CACCR9, MANWA7S, REtttitN LIpES, OtUER <br /> rRASE II VA[•OR RECOVERT SISTEMI BALANCED, ASPIRATOR ASSISTED, LONG RUN WEI•L3, MANIFOLD®. <br /> TVID•ITIG STS SVCtI TURBINE MARE jTQS.c..r+cam' . OTHER <br /> [� MODEL PIPE LINE LEAK.Detectors TES. RO p0T ATPLEC <br /> CHARTED SIZE pci EST. LINE QUANTIFY /-5- PRODUCT ADD® TU <br /> FLOM StSTEM S SYSTEM TONAL GALLONAGE./0000 <br /> A"IENT CO"DtttONSl TFHPI tRETEST&V POSTEST 1pVppr•1 <br /> //��/� /��� ---.`_- CLOVDT, MINING, NINOT R EZT, NICHT, OTHER <br /> .6 FSI DROQ'7� HOURS TEST TO STARP�•K� A -7 <br /> HOURS FSI TO BE MAINTAINED ON TANK BOLTON IMMIM TEST FtRIOD 'Y , rSF <br /> A. CXADR TO TANK BOTTOM �J���j��}� <br /> 0 ZD B. MADE TO TMK TOP -' / /Y <br /> 6•GfOI C. TR 01ABE 111 <br /> D. TEST LtEBL A" CMOR Z� <br /> ` gyp/r B E. ErTRPNAL MATER AAOVR tM[ <br /> F H BOfTO1 IM• R .0161 PSI . <br /> F. TOP VF FILL TO POW. AT MAjvAL <br /> C. TOP OF PILL TO TOP OF TARR S3} <br /> TVI.".1.7EL•TO amm OF tMR /}�� 17.1 1� <br /> RATER 1 IDB C R/_ PSt PRA INC" OF Pbd1L7 d�� <br /> 1 A I( TMR / TEST "EIOIr PRESSURE FOIMILA <br /> _ 46 y <br /> REMARKS: N. PSI e. rSI RET FS <br /> G.e2 6� �fo.�,v�- n.0 •tc�yer/ sT�r:�Tx� ¢.0�7' 0.�� ti1�ao�r- <br /> RESULTS . <br /> 9HE FINAL TESTRIO AS SHOWN ON THE ATTACIIED COMPUTER GENERATED DATA REFLECTS A <br /> OS / GAIN OF!/Aa GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/- -E� gPh• <br /> THE HORNER EZY CIIEK II TEST METHOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPM <br /> FOR TANK INTEGRITY TESTING. (SECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD, TWE RESULTS <br /> SHOWN ABOVE: ' DOES NOT INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPM STANDARD. <br /> INTEGRITY TANK TES I C EER�V�I}/C�E•SS,,, 166 FRANK WEST CIRCLE, STOCKTON, CA., 95206, (209) 466-8036 or (800) 262-8 78 <br /> CERTIFIED TESTER ry71,IJ(J STALE LICENSE / TEST DATE <br />