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{ <br /> • ! <br /> WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OG?IFR/OPERATOR /rG�/�'/LG�/t1� �r �' SITE ADDRESS <br /> CITY �T�CJ�CTZ} 1 ` . COUNTY <br /> HAILING ADDRESS <br /> SIIE ACE" /C C~ /�/�T� �} TELEFWONE (7t.;f) <br /> ARRIVEM TEST SI 'AOVRS TANK LOCATION PRODUCT <br /> DATE/TIME STORAGE FILLED*4RODVCT LEVEL ATffARRIVAL +7 INCHES AFLOW TOP Of FILL NOMINAL TANK SIZE G�f�JQ <br /> TANK MATERIAL._ APPROX. TANK A0460 T TRS. FILLSIZEITTFE 4 OVERFILL CONTAINMENT MEL <br /> API GRAVITTa 0pAT M'DEC. F. - Ari GRAVITY OF6t'/@ 6OF - COEFFICIENT OF EXPANSION OF .000 lF// v - COE C7 <br /> VISABLE VENTING APPRFARS TO HE ATt ILL RHD, FILL OFOSTTE END, HAS BURP TUBE, HAS HALL CHECK, OWN, OTHFY <br /> VISASLE VAPOR TRAPS TO BE BLED: BALL CHECKS, HANWATS, RETUTM LINES, OTHER <br /> PMSE II VAPOR RECOVERY SYSTEM: CED ASPIRATOR ASSISTED, LONG RUN WELLS, HANIFOLDED, NONE, OTHER <br /> PUHPINC STSTEH: UpCTIO TURBINE HAKE MODEL PIPELINE LEAK Detectors TES. NO NOT Arm <br /> CHARTED SIZE J EST. LINE QU / OD <br /> AN M /0 PRODUCT ADDIM TO FLOOD STSTM *.7 STSTEM TORAL GALLONAGE <br /> AMBIENT CONDITIONS: TFMP: PRETESTO/0 POSTES7 � CLOUDY, RAINING, WINDY, PREM, NIGHT, OTHER 3,7 <br /> .4 PSI DRO/A HOURS TEST TO STAR'S/°^' POURS PSI TO IRE NAIN ,�J <br /> 7AINED ON TANK BOTTOM DURIHG TEST PERIOD /,FjSI <br /> + X. GAAOF• TO TANK 1OTTUH p` <br /> B. GRADE TO TANK TOP Z a' <br /> ° <br /> C. TANK DTAf�E'T'ER 7 <br /> d tom?L7£ , <br /> /777 r D. TPST LEVEL hAOVF! GRADE <br /> j"'J G14]!� '� E. EXTERNAL GROUND MATER AEOVE TANK <br /> ��Z, �� BUTTON 1M, K .0361 PSI ^ <br /> F. 7Ofi OF FILL TU PROD. Al ARRIVAL <br /> G. TOP DF FILL TU TOP OF TANK <br /> H. 1'!_[1'"LB9EI'TU'71OTTOH OF TAMC <br /> C P51 PER INC11 OF P10DUCF � v - <br /> MATl1t 1"Flue <br /> TANK •. " ` TEST HEIQIT PRESSURE FURMH.A <br /> E < �- K OZ61 . _� - 3.67 <br /> N. PSI PSI NET PSI <br /> REMARKS: <br /> RESULTS <br /> 'F!]E FINAL TEST PERIOD AS SHOWN ON T11E A [ACHED COMUTER GENERATED DATA REFLECTS A <br /> SS / GAIN OF;,,�pCsGAI,LONS PER HOUR, WII'I! A 94% CONFIDENCE LEVEL OF +/- ■ - nh <br /> THE HORNER EZY CHEK II TEST METHOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGRITY TESSECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD, THE RESULTS <br /> SHOWN ABOVE: W ES NOT INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br /> INTEGRITY TANK TESTING IVICES, 41 WEST YOKUTS ST. STOCKTON, CA., 95207, (2009) 474-1375 or (80x0) 6`2-8378' <br /> CERTIFIED TESTER STATE LICENSE # l6-'o,�Jx3 TEST DATE l J L- <br />