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WORKSHEET FOR /SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OWNER/OPERATOR -y% <1,70 s v �iU/ �iQ/J �f SITE ADDRESS <br /> CITY 7j i��-.� COUNTY J <br /> HAILING ADDRESS <br /> SITE AGENT - TELEPHONE �) 4ne ;?7 <br /> ARRIVED TEST SITS/J41'/.4JLHLS TANK LOCATION �V G� /Z>�'�=/�"t DUCT Z'/ <br /> DATE/TINE STORAGE FILLELY(7 4 jOPARODUCT LEVEL AT ARRIVAL�INCHES BELOW TOP OF FILL NOMINAL TANK SIZE fZ-p Qom, <br /> TANK HATER LALe 1�2APPROX. TANK AGG�D�YRS. FILLSIZE/TTPEL'!�z OVERFILL CONTAINMENT TYPE <br /> API CRADITT AY �Z DEC. F. API GRAVITY OF� @ 6OF - COEFFICIENT OF EXPANSION OF _000 GAJ COE�'g 1 <br /> VISA.BLE VENTING APPREARS TO BE ATI FILL END FILL OPOSITE END, HAS BURP TUBE, NAS BALL CHECK, UNKNOWN, OTHER <br /> VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, MANWAYS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY SYSTEM EALANCED ASPIRATOR ASSISI LON RUN WELLS, MANIFOLDED, NONE, OTHER <br /> PUt{PLNC SYSTEM: UCTIo TURBINE MAKE GU MODEL PIPE LINE LEAK.Detectors YES, No, Q7�`N AFPLTC'$ <br /> CHARTED SIZE 1 Z��®U EST. LINE QUANTITY 6) PRODUCT ADDED TO FLOOD SYSTEM SYSTEM TORAL GALLONAGE <br /> AMBIENT CONDITIONS: TEMPI PRETEST?� POSTEST S`' CLOUDY, RAINING, WINDY, BREEZY, NICHT, OTHER <br /> .4 PSI DRO/LY o HOURS TEST TO STARTf�AIOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD s FSI <br /> - A. GRADE TO TANK BOTTOM _ T�/ <br /> G D E. CRAM TO TANK TOP <br /> C. TANK DIAKETER <br /> 6•PAAE 2 �ry <br /> ! 0. TEST LEVEL ABOVE CME O <br /> ®�--- E. EXTERNAL GROUND MATER MOVE TANK <br /> �j ,__ ®OTTCH 1N. R .0361 PSI - <br /> ! <br /> 047' 1/ F. TOP OF FILL TO P900. AT ARRIVAL <br /> AC. TOP OF FILL TO TOP OF TANK <br /> H. TE :3_lYEL'.TO'®OTTON OF TANK <br /> �'� <br /> NATER INSIDE c`J PSI PER INCH OF PP0DUCT <br /> E /� TANK •.. « � TEST HEIGHT PRESSURE FORMULA <br /> -� 1, 48 <br /> REPIARKS: H• PSI E. PSI NET PSI <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 991 CONFIDENCE LEVEL OF +/- gph, <br /> THE HORNER EZY CHEK II METHOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPA <br /> FOR TANK INTEGRITY TESTING. (SECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br /> SHOWN ABOVE: DOES DOES NOT INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br /> INTEGRITY TANK TESTING SERV 3, /P/.O.BOX 6913T6 STOCKTON, CALIFORNIA, 95269 (209) 474-13T5 or (800) 62-8 78 <br /> CERTIFIED TESTER U� 11 ` <br /> STATE LICENSE N s TEST DATE IJ <br />