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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OWNER/OPEAAIOR <br /> SITE ADDRESSSCG'C.i L .�����-r•�ICK,�/� <br /> CITY .�'Z�f-i��`�c� COUNTY <br /> MAILING ADDRESS <br /> SITE ACENT �j�t•�'i1'L SCG"G— TELEFTIONE �/��,� <br /> ARRIVED TEST SISE'� 1L5 iGA0USANK LO <br /> UTICN --�'T// �` ?.. PRODUCT eJ/i�- <br /> DATE/TDO: STORAGE FILLED S/Z-1 PRODUCT LECEI, AT/AARI4AL INCHES LE[,py TOP OF FILL NOMINAL TAMC SIZE <br /> TANK MATERIAL ' �o �" APPROR. TANK AGB- /' <br /> �� TRS. FILLSIZE/TYPE a OVERFILL CONTAIlD¢777 TYPE <br /> API CRAVITT 41 AT��DEC. F. - API CRAVITT OF-ZLL P 6OF - COEFFICIENT OF MANSION OF .0004coE � 7C <br /> VISABLE VENTING APPREARS TO HE AT: FILL no ILL OPOSIZE END, , RAS BURP TTIEE. AAS BALL CHECK, OINKIIO5D1, OIAF)N <br /> 71SABLE VAPOR TRIPS TO BE SLID: BALL CHECKS. HANctAT�$,—_ <br /> i RETURN LINES, OTHER <br /> P1LlSE II VAPOR RECOVERY STSTZ", BALANCED. ASPIRATOR ASSISTED, LONC RUN WELLS, IIANIFOLDED, ROME. J OTHER <br /> PUMPING SYSTEM: SUCTIOW. TURBINE <br /> MODEL. PIPE LINE LEAK Detectors YES, T APP <br /> OLI <br /> CHARTED SIZE/ ZC'GC EST. LZ(R�EPCDANTITYL PRODUCT ADDED TO FLOOD SYSTEM SYSTEM TORAL GALLONAGE ZZG'/�% <br /> AMNT TY18: PAEIESD J POSTLS CLOUDY. RAINING, WINDY, BREEZY, NICHT, OTHER <br /> .6 PSI DRMZ p0Up5 TEST 70 START,-5OURS""'PSI TO BE MAINTAINED ON TANK BOTTOH DURING TEST PERIOD 5, fl <br /> _ PSI <br /> A. GRADE TO TANK BUTTON lz 3 <br /> O -2 L�% t. GRADE TO TANK Top - z ,3 <br /> 6•�:Fd! C. TANS DIAIBTTER 95 <br /> —~ GROUND <br /> TEST LEVEL ABOVE GRADE 7- 0 <br /> - <br /> B^- E. EKTERNAL GD RATER NOK TAN[ <br /> F 1 BUTTON 7N, 1 .0361 Ps/ - <br /> /) �� <br /> Fly- F. TOP OF FILL To PAm. AT ARRIVAL <br /> G. TOP OF FILL TO TOP OF TANK <br /> 7.� <br /> H. T=713YEC-TG'IOTTa OF TANK r4 <br /> RATER C PSI PER INCH OF PRODUCT Q / <br /> E TANK / TEST/HEIGHT PRESSURE FORMULA <br /> REPIARKS: H. PBI C. r51 MET <br /> i <br /> RESULTS <br /> THE FINAL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS / GAIN OF: GALLONS PER HOUR, WITH A 99-% CONFIDENCE LEVEL OF +/— <br /> - 8Ph. <br /> THE HORNER EZY CHEK II METHOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGRITY TESTING(SECTION 2643 CALIFORNIA COAD OF REGULATIONS)BASED UPON THIS STANDARD THE RESULTS <br /> SHOWN ABOVE: DOES DOES NOT INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD <br /> INTEGRITY TANK TESTING DIV. OF OIL EQUIPMENT SERVICE, P.O.BOX 950, SAN ANDREAS,CALIFORNIA, 95249 (209)754_1808 <br /> CERTIFIED TESTER Lr� �/i1��_ LICENSE# <br /> DATE JI �% <br />