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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OWIfE0./OPERATOR <br /> /1 ,r SITE ADDRESS�:� Z7 _7_ <br /> cm sj�• <br /> CI7T <br /> NAILING ADDRESS <br /> SITE AGENT � t. TELEPHONE (�G� <br /> ARRIVED TEST 51 2429LHCUXS .TANK LOCATION /� PRODUCT <br /> DATE/TIME STORAGE FILLED /L PRODUCT LEVEL A7 ARRIVAL -INCHES BELOW TOP OF FILL NOMINAL TANK SIZE �j <br /> TANK MATERIAL <br /> !,4�9G G s'y-&6�/�7 APPROX. TANK ACB�TRS. FILLSIZE/TYPE '5- OVERFILL CONTAINMENT <br /> APT CRAVITTTe AT DEC. F. - Apt GRAVITY OF.�' P 6OF - COEFFICIENT OF EXPANSION OF .000 loYv.J,s(7 - COE lib <br /> VISABLE VENTING APPRPARS TO BE AT: FILL END, FILL OPOSITE IIID, HAS BURP TUBE, RAS BALL CNECR =OWN�OTHER <br /> VISABLE VAPOR TRAPS TO BE BLED: BALL CAECKS, MANVATS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY SYSTEM: ALANCED <br /> ASYIRAIOR ASSISTED, IANC RUN '.1H.LS, HANIFOLDID, NOpE, OTLiIIt <br /> PUMP INC SYSTEM: SUCTION, TURBI}nl NAKL TC-l--,V�-'7/S/j EDDd PIPE LINE LEAK DeteCtO TESI' ; NOT APPLIC <br /> CHARTED SIIE, EST. LIIMQQDANFI77 -5' PRODUCT ADDED 70 TWOD SYSTEM-57SYSTEMTORAL GALLONAGE /� <br /> AMBIENT CONDITIONS: TEMPI PRETEsT,5;; POSTEST <br /> .4 PSI DR � CLOUDI, RAINING, WINOS EZTi�NICAT, OTHER �T p00R5 TEST 70 57ARyAOURS PSI TD BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD Ori <br /> / PSS <br /> A. GRADE TO TANK ROnON <br /> R. GRADE TO TANK TOP <br /> C. TANK DIAMETER 1412- <br /> 0. <br /> 2- <br /> 6.PA.OE _ <br /> z <br /> D. TEST LEVEL ADM GRADE <br /> E. BKTERNAL GROUND RATER ABOVE TANK <br /> KOTFONIN, t .0]61 P51 <br /> fF. TOP OF FILL TO PE00. AT ARRIVAL ��jG. TOP OF FILL TO TOP OF TANK 3H. m7niBYEL'.Tvlona" 0P TANK /4-6 <br /> PSI PER INCH OF PROM= <br /> TEST HEIGHT PRESSURE FORMULA <br /> 14G 6,761 1� <br /> REMARKS: H. PSI C. TSI NET P5, <br /> RESULTS <br /> THE UNAL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS / AIN F: 4,x W GALLONS PER HOUR, WITH A 99z CONFIDENCE LEVEL OF +/- -4a ' gph, <br /> THE HORNER TZ`(CHEK II METHOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGRR�CTION 2�CALIFORNIA COAD OF REGULATIONS)BASED UPON THIS STANDARD THE RESULTS <br /> SHOWN ABOVE: OES NOT DICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD <br /> INTEGRITY TANK TESTING OIL OIL EOUIPMENT SERVICE, P. 0.BOX 950, SAN ANDREAS,CALIFORNIA, 95249 (20 )754-1808 <br /> CERTIFIED TESTER �L '<� LICENSE#_ �CZ — DATE 8 9 <br />