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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY �! ] <br /> O4RIER/OFERA70R SITE ADDRESSYlir����� i�/ <br /> CITY CovurY <br /> MAILING ADDRESSL;� Of � / <br /> SITE AG£.NT L- � /f r'�y // TELEPHONE J G] zQ <br /> ARRIVED TEST SIT��1701M TAM LOCATION Cl���[�Cl� PRODUCT <br /> DATE/TYNE STORAGE FILLED /2 PRODUCT LEVEL AT ARRIO INCHES BELOW TOP OF FILL HMINAL TANK SIZE Z2 <br /> TANK MATERIAL l j �� '-AFPROX. TALAR AGR` YRS. FILLSI7.E/TYPE 4 OVERFILL CONTAINMENT TYPE <br /> AFI GRAVIT AT /,3IJF.G. F. - AFI GRAVITY OF � r SOF - COEFFICIENT OF EXPANSION OF .000 _ �J - COE <br /> VISABLE VENTING AFFRPJIILS TO BE ATI FILL END, F L OFOSITE HAS BURP TVBE, HAS BALL CHECK, UNKNOWN, OTHER <br /> VISABLE VAFOR TRAPS TO BE BLED' BALL CHECKS, MANWAYS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY STSTEH: ALANCEb, ASPIRATOR ASSISTED, LONG RUNrWELLS, MANIFOLDED, NONE, OTNER <br /> PUMPING SYSTEM: SUCTION, INE HAKE MODEL 5'J"0 FIFE LINE LEAK DeteCtoa 7P.S, No; NOT AFYLIC <br /> CHARTED SIZE/2—i:200 EST. LINE QUANTTTT-/& PRODUCT ADDED TO YLOOD SYSTEM ILI, STSTEH TORAL GALLONAGE 12_z:!;'2 �- <br /> AMBIENT CONDITIONS: TEM'r FRETEST�POSMT f;5- TTiT, CLOUDY, PAINING, WINDY, BREEZY, NIGHT, OTHER <br /> .4 FSI DRO� �OURS TEST 70 START/OURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD 413 FSI <br /> A. GRADE TO TANK eOiTUH /33 <br /> GRADE TO rAHX TOP � <br /> C. TANK a1A�fET£A <br /> D, TEST I.evPL AaovE GRADE <br /> E. EXTERNAL CROUFtD MATER ArOVE TANK <br /> � (j � � ~r SOrTOH 111. X .0]61 PSI <br /> �3 F. TOP OF FILL TO P000. AT ARRIVAL 133 <br /> �[✓.1 G. TOP OF FILL TO TOP Of TART. _5 <br /> H. TLST,UtM-TO e0TTOM OF TANK, <br /> C`7 T51 PER ING11 OF PPCMXF Qom' <br /> HATER 1 D! <br /> T. " f TEST NEICTIT PRESSURE FORMULA <br /> H. PSI E. FS1 NET PS1 <br /> REWKS <br /> RESULTS <br /> Tg FINAL T IOD AS SHOWN ON THE ATTACIIED COMPUTER GENERATED DATA R}: LF TS A <br /> LOSS / GA N OF: GALLONS PER HOUR, WTTII A 99% CONFIDENCE LEVEL OF +/ - � pull. <br /> Opo <br /> THE HORNER EZY CHEK II METHOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOP. TANK INTE T ING. SECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD, THE RESULTS <br /> SHOWN ABOVE: S S INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPF STANDARD. <br /> INTEGRITY TANK TESTI R CES, 41 WEST YOKUTS ST. STOCKTON, CA., �9}5207,, (209) 474-1375 or (800) 3p2-8)7& <br /> CERTIFIED TESTER STATE LICENSE 0 ?J �(J � TEST DATE <br />