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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> t <br /> OWNER/OPERATORi9G 4 /1. T« �ix _ <br /> SITE ADDRESS�T-• .;= r�'�is-� <br /> CITY �• '--�i�^-.�C� -Yip JCri�cij' <br /> �7 COUNTY-- ✓ y <br /> NAILING ADDRESS ` G'.�c:,✓- rGj pf--� �� <br /> SIIE AOEF7I TELEPHONE ���� / 7�-✓ <br /> ARRIVED TEST SSZFj�ROURS TANK LOCATION__ .S �,v�� /J/f/�v.J!��P/ PRODUCTG <br /> DATE/TIME STORAGE FILLED �� <br /> PRODUCT LEVE, AT ARRIVAL <br /> ----IOAL INCHES BELOW TOP OF FILL NOMINAL TANK SIZE <br /> TANK HA2LRUIL APPROX. TATA( ACE/ FILLSIZE/T7PE G OVERFILL CONTAIHDIPN7 TYPE =:,::�d��L�� <br /> API GRAVITY f7 AT 72 DEC. F. - ApI CRAVIIY OjEf -j p 6OF - COEFFICIENT OF EXPANSION OF .000 J - COE <br /> VISABLC VETTING APPAEAAS IU DL ASt FILLFILL OPOSIIE END, RAS BURP TUBE, RAS BALL CHECK, ONE70TAM, OTHER <br /> i� <br /> VISABLE VAPOR TRAPS TO BE DLID: BALL RWLCCS. MANWAYS, RETURN LINES, OTHER <br /> PEASE IT VAPOR RECOVERY STSTLM• BALANCED, ASPIRATOR ASSISTED, IARC RUN MLS. MARTFOLDED, .NOEL, OTHER <br /> PUMP INC STSTEf CSIORE TURBINE MAXI •IJ MODEL PIPE LINE LEAK.DetectorE TLS, N0, AOT APPC <br /> CRARTED SIZE eQOC% EST. LINE QOANTIIT_.�- PRODUCT ADDED TO FLOOD SYSTLHr SYSTEM TONAL EMGALLONAGE <br /> '�j�/O <br /> AMBIENT CONDITIONS: TEMPT PRET T7z—POSTwY <br /> ,�MM � 7 CLOUDY, RAINING, WINDS, BREEZY, NICHT, OlAEt_ <br /> .4 PSI DRDPryH <br /> � 00RS TEST 70 START/ZL�AOURS PSI To BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD �•LS <br /> PSI <br /> { A. CRAVE TO TANK SDFMFR <br /> 0- B. CURE TO TANK TOP ✓p�C <br /> !TANK -.. C. TANK DIA%mYMx /JD. TEST LEVEL ADM CUM d� !. CZYBRNJIL GfCUN tAliR AbVE TANK �.o36i PSIF. TOP OF FILL EO PAW. AT ARRIVAL <br /> C. TOP OF FILL TO TOP OF TANK <br /> H. TLTT7J2TWTO"&OROH OF TANKDE PSI PBX INCH OF PwmlC! <br /> E— / TEST xEIRNT ►IILSSURE FOIOKR.A <br /> RE?LARKS: NET nM <br /> RESULTS <br /> TAL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSSGA OF: -f03/ GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/- ,ppm gph, <br /> THE HORNER EZY CHEK II COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGR ON 2843 CALIFORNIA COAD OF REGULATIONS)BASED UPON THIS STANDARD THE RESULTS <br /> ABOVE OES NOT DICATE AN UNAUTHOR�D RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD <br /> INTEGRITY TANK TESTING DIV. OIL EQUIPMENT SERVICE, P.0.BOX 950, SAN ANDREAS,CALIFORNIA, 95249 .(209)7547808 <br /> CERTIFIED TESTER LICENSE# 7� �c`��' DATE --- �c� 9 <br />