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Page *3 - 5 SITE PREPARATION AND SYSTEM DATA CHECK TANK SYSTEM SIZE 1 - TANK � 2 - TANK = 3 - TANK CUSTOMER: f / J' t'' j L DATE: LOCATION NO.: � ` /1 SYSTEM NO.: CITY/STATE: _ f 1 U0C I*U� � PRODUCT: 67, SITE PREPARATION VAPOR RECOVERY ❑ PLUGS 17 RISERS ❑ OTHER VENT ❑ NO PREPARATION ❑ PEN TO ATMOSPHERE ❑ P -V VALUE REMOVED ❑ OTHER ❑ REMOTE/SUBMERSIBLE (DEPTH 1 ❑ SUCTION (HEIGHT ) CHECK VALVE STRAINER IMPACT VALVE CHECK VALVE STRAINER SUCTION NECTION ❑ REMOVED & OPEN N PLACEPLACE ❑ REMOVED __- ❑ CLOSED PLUG-IN E] CLOSED T ❑ BURIED ❑ EXTRACTABLE ❑ REMOVED ❑ IN PLACE ❑ UNION ❑ COUPLING ❑CLOSED ❑ REPLACED REMOVED ❑ OTHER ❑ REPLACED &COVER ❑ OTHER LJ OPEN [:]REMOVED ❑ IN PLACE E:] C'REP D & D ❑ RREM ACED& COVER OTHER ❑ OPEN WITH FOIL ❑OPEN NO FOIL ❑ IN PLACE other (Specify) IN OUT ❑ OT R T. PROBE ❑ OTHER t1 6Q / AVG. CC'S/DIV. -�✓ TEST 1 DATA LEVELS TANK 1 TANK 2 TANK 3 LOCATION DROP TUBE LOCATION DROP TUBE LOCATION-- DROP TUBE 5 FILL Gauge Other (Specify) IN OUT None FILL Gauge Other (specify) IN OUT 1pa C LJ Gauge other (Specify) IN OUT None T. PROBE ? �S t1 6Q / AVG. CC'S/DIV. -�✓ ± Temp. Differential "�� TC = T Time of Temp. BALANCE y - Differential, Min. Time LEVELS CALIBRATION Time I Tank 1 1 Tank 21 Tank 3 START �•l� 4 5 '"'� END CC'S ❑ C ❑ OTHER TC = TANK 1 TANK 2 CALIBRATION LOCATIO ' METHOD �,y''' L'J SOLID ROD ❑ LIQUID 3785 GT CE CC IN OUT TC = - OR 1 2 3 4 5 6 AVERAGE CC'S ❑ C ❑ OTHER TC = TANK 1 TANK 2 93 / SYSTEM CAPACITY, GALLONS6 �bo GT DIVISION a TANK 2 TANK .f � A°F ? �S t1 6Q / AVG. CC'S/DIV. LEAK RATE ILA)CALCULATION LR = ±A DIVISIONS X CALIBRATION, CC = CC IN OUT OMINUTE DIVII�SION MINUTE LR = ` L' ( _ 0 TEMPERATURE COMPENSATION (TC) CALCULATION COEFFICIENT OF EXPANSION 1/.F ' 4 DAF - GRAVITY TEMPERATURE, F 3785 GT CE CC IN OUT TC = - OR ❑T159C TIME MINUTE SOURCE ❑ A ❑ D ❑ CHART ❑ B ❑ E ❑ PUBLISHED DATA AT 60OF ❑ C ❑ OTHER TC = TANK 1 TANK 2 93 / SYSTEM CAPACITY, GALLONS6 �bo GT TANK 1 TANK 2 TANK .f TOTAL A°F A°F ± Temp. Differential TC = T Time of Temp. Differential, Min. Time A135ULUIE LEAK RATE (ALR) CALCULATION ABSOLUTE LEAK RATE _ _ I ' — -3,-13 rL( _ � (_\ LEA'r, RATE TEMP. COMPENSATION,\ ,CIC/MIN "•I •�/ IliJ�' X 0.015852. _ U V i ,I I+_-.s�""`3 1 C', CC/MIN GAL/HOUR*r ❑ IF ALR i ± 0.05 GPH, A CHECK TEST WAS CONDUCTED WHICH CONFIRMS THE ABOVE RESULTS (CALCULATIONS��ffSHAR Eltz) �� A CHECK TEST WAS NOT CONDUCTED. T JJ1l ` 60 MINUTES/HOUR - 3785 CC/GALLON = 0.015852 E dN!R01 �i1�lENTAL HEALTH I"ERf iT/SERVICES