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I <br />( . ' 0 • • 0 <br />WORKSHEET" FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br />mwER/OPERATOR �C C/c�/ � �% 11f �s��/ SISE ADDRESS_^ - <br />C 17 � COUNTYiCl�' <br />MA.ILINC ADDRESS <br />SITE ACE14r TELEPHONE <br />ARRIVED TEST SIytv�5n JRS1 TANK LOCATION j�G ��// PRODUCT <br />DATEITIn STORAGE FILLEA� /G D RODUCT LEVEL AT77AA/PMVAL/ C INCHES BEL0W TOP OF FILL ROKINAL TANK SIZE_4:, � sQ <br />IAFK HATERLGU' L.� APPf�z. TANK AGE- - TRS. FILLSIZEITTPE � ME <br />07ERFILL CONTAINMENT TYPE <br />API CRAVITT�`*" AT WDEC. F. - API CRAVITI OF e 60F - COEFFICIENT OF EZPANsioN OF .00O 47-zz; - COC 4 7 z <br />VISABLE VENTING APPRPARS TO BE AI FiI�FILL OPOSIIE END, RAS BURP TUBE, HAS BALL CHECK ER - <br />VISABLE VAPOR TRAPS TO BE BLED: BALL CBECXS, MANVAIS, RETURN LINES, OTRER <br />Sty" <br />PHASE II VAPOR RECOVERY SISTEM�BC72;7__:�/ ASPIRATOR ASSISTED, LONG R , IFOLAID, HONE. OTHER <br />PUMPING SYSTEM: SUCTION TURSINZfJ MAX1 / r ' � MODEL PIPE LINE LEAK DeteCt:O TE , NO; NOT APPLIC <br />CHARTED SIZE <br />�> � ESI. LIPS C�UAH'LIII� PRLIDUCI ADDED TO FLOOD STSTl2S � S'LSTPZS iORAi. CALLONACE�_� <br />AMBIENT CONDITIONSt IEiO': PREIPSI�'�,P�OS�!TLSTy SUNIR, 'CLOUDY, RAINING. WINDY=BRY=T }{ICHI. OTHER <br />.4 PSI DRO/AV HOURS TEST TO STAR�'WROURS PSI TO BE MAINTAIMM ON TANK BOTTOM DURING TEST PERIOD � PSI <br />A. CAADE TO TAN[ IOTTOM <br />- D � <br />V. GRAD! TO TAIL[ TOP <br />C. TANK OIAjETER <br />6G1JiE 7 <br />D. TEST LEVEL ABOVE GRADE <br />_. 7 RiAC' <br />` /-T E. EITEL WL*M WATER MOVE TAN[ <br />G• F ttOTTvm IH.:.ossl PSI <br />F. TOP OF FILL TO PAW. AT ARRIVAL <br />Z C. TOP OF FILL TO TDP OF TARK � �Z <br />Xh H. TEST:.ISM'TO70TTOH DF TA?M <br />(��/�C� e PSI PER INCH Or PMULcr ✓� <br />HATER INWSOE <br />TAHI ff • J TEST HEICHT'TRPSSURE FOYAT.A <br />H. SI PSI a51 NET P51 <br />REMARKS: <br />RESULTS <br />THEFlHAL TEST PERIOD -AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br />LOSS / E <br />N OF ;QZ GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +f- ,dc� gph. <br />THE HORNER EZY CHEK 11 M D COMPLIES WrM EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br />FOR TANK INTEGR ON 2643 CALIFORNIA COAD OF REGULATIONS) BASED UPON THIS STANDARD THE RESULTS <br />SHOWN ABOVE: ES NOT NDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD <br />INTEGRITY TANK TESTING DIV. OF. L EQUIPMENT SERVICE, P. O. BOX 950, SAN <br />/ANDREAS, CALIFORNIA, 95249 (209 754-1808 <br />CERTIFIED TESTER LICENSE # <br />