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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br />OWNER/OPERATORG" ,o,00. !,c-�.e Al%`�G�/��G� _'FluggE ADDRESS(( 4 0 <br />_�5I�7,: Gj�it'J <br />CITY �TRiGp/�''t?/C% r COUNTY <br />MAILING ADDRESS <br />SITE AGENT 19c%� /i/�F / G ?/ ��,c TELEPHONE (7/ <br />ARRIVED TEST SITE' HOURS TANK LOCATION �/4�T i9� f�L�iQ�i/UF PRODUCT <br />DATE/TIME STORAGE FILL 2 40 ,yPRODUCT LEVEL AT ARRRIVAL ''V INCHES BELOW Tor OF FILL NOKINAL TANK SIZE r% <br />TANK HATERLAL ® n/ APPROX. TANK AGEgrp YRS. FILLSIZE/TYPE T OVERFILL CONTAINMENNT TYPE <br />API CRAVITT -3�% /AT / DEC. F. - API GRAVITY OF ,V @ 60F ® COEFFICIENT OF EXPANSION OF .000 44415'. COE 444 <br />VISABLE VENTING APPREARS TO BE ATS FILL END, FILL OPOSIYE END, HAS BURP TUBE, RAS BALL CHECK, UNKNOWN OTHER <br />VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, MANWAYS, RETURN LINES, OTHER "���� <br />PHASE II VAPOR REC VERY SYSTEM: BALANCED, ASPIRATOR ASSISTED, LANG RUN WELLS, HANIFOLDED, ONE OTHER <br />PUMPING SYSTEM:... vll�� Oo� e -e-- <br />SUCTION, TURBINE HAKE MODEL PIPE LINE LEAK .Detectors YES, NO; NOT APPLIC <br />CHARTED SIZE —'r&kn EST. LINE QUANTITY J PRODUCT ADDED TO FLOOD SYSTEM as SYSTEM TORAL GALLONAGE <br />AMBIENT CONDITIONS: TEMPS PRETESL5l?P�OySrEST CLOiIDY, RAINING, WINDY, BREEZY, NICRY, OTHER <br />.4 PSI DRO HOURS TEST TO STAR/ 47 HOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD ¢, Z -PSI <br />6.E'i4AE <br />0 <br />REPIARKS : <br />MATER INSIDE <br />TANK •.7-, a <br />A. GRADE TO TANK BOTTOM '/ �6, i5t <br />O B. CRAVE TO TANK TOP 7/ Y¢ <br />C. TANK DIAWTER 45' <br />% 1 D. TEST LEVEL ABOVE GRADE P <br />E. ERTERNAL CoUND MATER ABOVE TANK `> <br />BOTTOM IN. X .0361 PSI - <br />i z/ <br />F. TOP OF FILL TO PAW. AT ARRIVAL <br />C. TOP OF PILL TO TOP OF TANK l�tl <br />H. TEST:'JI EL'.TO 10TTOH OF TANK <br />C PSI PER INCH OF PRODUCT <br />TEST HEIGHT PRESSURE FORMJLA <br />60 X e3 7 - <br />H. PSI FSI NET PSI <br />RESULTS <br />HE FINAL TEST PERIOD -AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br />OS / GAIN OF;, -.O//— GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/— coop gph. <br />THE HORNER EZY CH K 4D COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <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 6913T6 STOCKTON, CALIFORNIA, 95269 (209) 4T4-1375 or (80 ) 2 -8378 <br />CERTIFIED TESTER i STATE LICENSE I '' C) TEST DATE <br />