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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br />7u7:ER/0FERAi�OR7�7<f t!7 /►.IJ,,Ci Tfrf � ,j�'�CC,i� ��, SITE ADDRESS /'S L�•` � J-� � �yvvaa <br />C I TT <br />COUNTY-- ;. -L_ sc�7r% <br />MAILINC ADDRESS <br />SITE ACE}TT <br />., � TEI.EPAONE ( ) <br />ARAIDEA TEST SIZr AOT TANZ LOCATION <br />PRODUCT <br />DATEYTI]IDE STORAGE F£LLED���� PkODUCT LEVET. AT ARJUICAL� <br />INCHES BELOW TOP OF FILL NaKINAL TANK SIZE <br />TANK MATERIAL TAN14 AGS���,, FILLSI2E/TTPE <br />API CRAPITL� AT 'DEG. F. AP1 GRAPITT OF <br />ZL 8 60F �ERF£IL CONTAINi�yn TypE_ <br />- COEFFICIENT OF EXPANSION OF .000 7�%Y_;;�_ - COE <br />DISABLE PENTINC APPRPARS To BE AT: FILL END, LL OPOSITE END <br />HAS BURP TUBE, AILS BALL CHECK. UNKNOWN, OTHER <br />DISABLE VAPOR TRAPS TO BE BLED: BALI, CHECKS, HANWAtS, <br />RETURN LINES, OTHER <br />PHASE II VAPOR RECOVERY StSTEH: BALkNCED. ASPIRATOR ASSISTED. LONG RUN WMLS,y HAAIFOLDED, NONE0 0 E <br />PUMPING Sts SUCTIO . TUP31HE HAXL <br />H0D PIPE LINE LEAK -Detectors YES. <br />CHARTED SIZE /� EST. LIRE QIIAIgTIT7 PRODUCT ADDED TO FLOOD SYSTEM 4 STSTEH TORAL GALLONAGE / Z f s SIC) <br />:.Y 1 <br />AMBIENT CONDITIONS; TEMPI PRETFST/-T-POSTEST � � � �• <br />-f SLINKY CIOUD2, RAININ i7IHdE~ „ NIGHT, OTHER <br />.6 PSI DROP /�-�OU S TEST TO STARy ROURS PSI To BE MAIPTAINID ON LANK BOTTCi( DURING TEST PERIOD e_:' <br />PSI <br />X. GRADE TO TANK 1Onum <br />p 1. CRAVE TO TANK TOP <br />�GP,p C. TAKK CIA -=R <br />0. TEST LEVEL ABOVE GUM <br />AZ E. lXiERNAL GAOM WATER ASOVE TANK <br />F BOTTW IN, 1 .0361 PSI <br />LTAXKry F. TOP OF FILL TO PkOD. AT ARRIVAL <br />�..- - <br />A C. TDP OF FILL TO TDP OF 7ANK <br />H. TLST-j.ETEL'TOIOT Cm IIT TANK C PSI PER INCH Of ?ROD=E/ TEST HEIGHT PRESSURE FORMICA <br />.x- _ <br />RE21ARKS:i ,vim �_H. P51 PSI NET PSI <br />'q:;; <br />RESULTS <br />TH L TEST PERIOD -AS SHOWN ON THE ATTACHED COPIPUTER GENERATED DATA REFLECTS A <br />LOSS CAI OF;_AC__vGALLONS PER HOUR, WITH A 997, CONFIDENCE LEVEL OF +/- Oc3 gph . <br />THE HARKEN EZY CHEK 11 M COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GpH <br />FOR TANK INTEG G (S ON 2643 CALIFORNIA COAD OF REGULATIONS) BASED UPON THIS STANDARD THE RESULTS <br />SHOWN ABOVEF DOES NOT 1 ICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD <br />INTEGRITY TANK TESTING DIV. OF L EQUIPMENT SERVICE, P. 0. BOX 950, SAN ANDREAS, CALIFORNIA; 95249 (209) 754-1808 <br />CERTIFIED TESTER I. <br />ze A <br />�--�� LICENSE #T DATE �� <br />