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z <br /> WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OWNER/OPERATOR {7 J�C�G.�L A- T/�r� ,�-��L- SITE ADDRESS <br /> ^ <br /> CITY COUNTY <br /> NAILING ADDRESS L.C�//- ��C�' 15�'52'L 5- <br /> SITE: <br /> SITE AGENT CCL 2GC_ �J�c�G.G��L'��«-� / TELEPHONE (=L��) <br /> AAAICID SE57 SITCHOIIfLS! TAHK LOCATION4 _-T/�--� PRODUCT <br /> DATE/TINE STORAGE�fFIL�LE�D S/7 PRODUCT LEVEL AT ARRIVAL_2_INCHES BELOW TOP OF FILL NOMINAL TANK SIZE <br /> TANK MATERIAL rf1J .J AP PROS. TANK AGER �TRS. FILLSIZE/TTPE OVERFILL CONTAINMENT TTPE �-'f,— <br /> API GRAVITTY/AT � -DEC. F. - API GRAVITY 0631 '7�e 6OFF - COEFFICIENT OF EXPANSION OF .000 `f-�U��- COE `5 7=' <br /> VISABLE VENTING APPREARS TO BE AT: FILL RID, FSLL OPS OSITE FND�! HAS BURP TUBE, HAS BALL CHECK, MTKNOVN, OTAFR <br /> VISABLE VAPOR TARPS TO BE BLED: BALL CHECKS, HANWAIS, RETURN LINES, OTHER <br /> PB/uE II VAPOR RECOVERY SYSTEM! BALANCED, ASPIRATOR ASSISTED, IANLS, MANIFOLDED Non OTHER <br /> �PUMPING SYSTEM: SUCTION, TURBIHEC � C/�L'LL�NODPIPE LINE LEAK Detectors TES, N0; T APPLIC\' <br /> CRAATED SIZE . ZC-GC EST. LINE OTIANTIT7_z_<:2 PRODUCT ADDED TO FTAOD SYSTEM (f)SYSTEM TORAL GALLONAGE IZoiz� <br /> ADIENT CONDITIONS: ���ITTIONS: TPHP: PRETEST ePOSIPST� CLOUDY, RAINING, WINDI, BREEZY, NIGHT, OTHER � <br /> .A PSI DROF;� ' HOURS TEST TO S7ART,� HOURS PBI IT) BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD - "51'5 PSI <br /> A. GRAD! TO TANI BOTTOM <br /> 011 . <br /> = B. GRADE TO TANK TOP <br /> C. TANK DIAMETER <br /> 6.G'IOF <br /> —.—� D. TEST LEVEL ABOVE GRAD! <br /> • Yom' r , e E. ESTERNAL CXUID WATER NOV! TANK <br /> G F— ROTIH IN. K .0161 PSI <br /> N F. TOP OF FILL TO PAW. AT ARRIVAL <br /> A/Z G. TOP OF FILL TO TOP OF TANK <br /> H. T?=:JAM-TQIORd OF TANK <br /> / RATER IN C! C 7 l PSI PER INCH OF PbOUCT <br /> E �1 TNR ((�C / TEST HEIGrr PRESSURE FORMILA <br /> REMARKS: H. nl C. PSI NET PSI <br /> s <br /> RESULTS <br /> THE F-I411 TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/- <br /> 8Ph. <br /> THE HORNER EZY CHEK II MEUJOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGR 17 ON 2543 CALIFORNIA COAD OF REGULATIONS)BASED UPON THIS STANDARD THE RESULTS <br /> SHOWN ABOVE S NO INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD <br /> INTEGRITY TANK TESTING DIV. OF EQUIPMENT SERVICE, P. 0.BOX 950, SAN ANDREAS, CALIFORNIA, 95249 209)754.1808 <br /> CERTIFIED TESTER LICENSE# 9D--./DLA DATE -� I3rJ <br />