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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br />OWNER/OPERATOR4E;�-.40/CJO^*'�4,,64E`' /V J`-Co/✓G_ 4;�?0/991E ADDRESS <br />((^^409/,!s) A1,c: ' - GjQ,tJ <br />C I TY �7 E� f%'"L?/G% COUNTY tiJy ii7[/ �leJC/` <br />?SAILING ADDRESS 49 /1 /6`2 G"ff �'7r �•�a.Q j^ �� 6�1 • �+ <br />SITE AGENT�/ '� M / Z4 -e4>1 /6&z -e.. TELEPHONE <br />�j <br />ARRIVED TEST SITE' HOURS TANK LOCATION F.'/�%� ®/L 4&44MA" PRODUCT A%,7 O.«... <br />DATE/TDM STORAGE FILL Z 340 PRODUCT LEVEL AT ARRRIVAL 2-/ INCHES BELOW TOP OF FILL NOMINAL TANK SIZE � d <br />TANK MATERIAL ® APPROX. TANK ACEO'O YRS. FILLSIZE/TYPE T OVERFILL CONTAINMENT TYPE ®/o <br />API GRAVITY 30- /AT 61 DEC. F. - API GRAVITY OF .410 @ 6OF - COEFFICIENT OF EXPANSION OF .000 444!.5'- COE 44-1 <br />VISABLE VENTING APPREARS TO BE AT* FILL END, FILL OPOSITE END, HAS BURP TUBE, HAS BALL CHECK,UNKNOWN OTHER <br />VISABLE VAPOR TRAPS TO BE BLED* BALL CHECKS, MANWAYS,RETURN LINES, OTHER � _ga <br />� <br />PRASE IT VAPOR REC VERY SYSTEM* BALANCED, ASPIRATOR ASSISTED, LONG RUN WELLS, HANIFOLDED, ONE OTHER <br />PUMPING SYSTEM- SUCTION, TURBINE MARE P MODEL PIPE LINE LEAX .Detectors YES, NO; NOT APPLIC <br />CHARTED SIZE � EST. LIKEQUANTITYJ PRODUCT ADDED TO FLOOD SYSTEM � SYSTEM TORAL GALLONAGE <br />AMBIENT CONDITIONS: TEMP* PRETESt d POSTEST CLOUDY, RAINING, WINDY, BREEZY, NICRT, OTHER <br />4 PSI DRO HOURS TEST TO STARTf 49 HOURS <br />64°i4AE <br />MATER INSIDE <br />NK <br />7A K <br />REPIARKS : <br />PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD Z -PSI <br />A. GRADE TO TANK BOTTOM —ZZ-6 <br />B. GRADE TO TANK TOP// I Y <br />C. TANK OIAW"R `-57 <br />D. TEST LEVEL ABOVE 'GRADE &) <br />E. EXTERNAL GROUND MATER ABOVE TANK a' <br />_ I /* BOTTOM X .0361 PSI - } <br />F. TOP OF FILL TO PQOD. AT ARRIVAL / <br />A ` C. TOP OF PILL TO TOP OF TANK I <br />H. TEST:.LBVEL'.TO BOTTOM OF TANK <br />¢s I --, <br />PSE PER INCH OF PRODtICI' <br />TEST HEIGHT PRESSURE FORMULA <br />N. PSI PSI NET PSL <br />RESULTS . <br />HE FINAL TEST PERIOD -AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br />OS / GAIN OF.:,,.Q,(/- GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/- root gph. <br />THE HORNER EZY C K COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 CPR <br />FOR TANK INTEG I Y ING. SECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br />SHOWN ABOVE: OES NO INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br />INTEGRITY TANK TEST V CE P.O.BOX 691376 STOCKTON, CALIFORNIA, 95269 (209) 474-1375 or (80 ) ;2&2-8378 <br />CERTIFIED TESTER i STATE LICENSE M TEST DATE <br />