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WORKSHEET FOR <br />SUBMITTAL TO GOVERNMENTAL AGENCY �l <br />OUNERfOFERATOR /��� f'i�I%/�-✓<77� f/ %!/ ADnRESS `4( <br />CITY ��-��' ` COUNTY <br />HAILING ADDRESS / <br />SITE ACETTI U � J TELEPHONE ( ) 7r%6 <br />ARRIVED TEST SI<��OURS T//AHK LOCATION �TZ-, PRODUCT✓ G /� <br />DATE/TIRE STORAGE FILLED PRODUCT LEVEL ATARRIVALEL <br />�IVAL INCHES BOW TOP OF FILL NOMINAL TANK SIZE <br />TANK MATERIAL APPR01[. TANK ACFcTRS. FItLSIZE/TYPE - OVERFILL CONTAImmn TYPE. <br />AFI GRAVITa-5 AT4�/70 DEG. F. - API GRAVITY CF5F5 0 60F - COEFFICIENT OF ERFANSION OF .000 C��--� - COE � JS <br />VISABLE VENTING APPRPARS TO BE AT FILL FILL OPOSITE EFTTI, HAS BURP TUBE, HAS BALL CHF,CK, t1TTKN(IiH7, Fit y <br />VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, MANWATS, RETURN LINES, OTHER <br />PRASE 11 VAPOR RECOVERT SYSTEH' ALANC ASPIRATOR ASSISTED, NC RVN WML IFOLDED, PONE, OTTaFR <br />PUMPING STSTP* SUCTION, RA BARE �� '1q« "'- MODEL PIPE LINE Lth]C Detector TE lap; N04 APPLtC <br />CHARTED SI7E/OL01:n�) EST. LIFE QUANTITY211 PRODUCT ADDFI) TO FLOOD STSTEH --5" SYSTEN TORAL GALLONAGE <br />i <br />AMBIENT CONDITIONS: TEMP., PRETEST�POSTEST 6UNN RAINtNC. WiNDT, RREE , NIGHT, OTFER C� <br />.4 PSI J)P69IT7� HOURS TEST TO STAR.706t'� HOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURINC TEST PERIOD f TSI <br />A. CRAKE TO TANK ROTTOH ` <br />-30 <br />0. MkM TO TANK TOP <br />o <br />C. TANK 01Ak1ETER <br />6.Pi?AE' D. TPST LEVEL ABOVE GRADE <br />i <br />E. E7[TERNAL GROUND MATER ABOVE TAN[ <br />ROTTC!( IM. R .0361 PSI <br />F. TOP OF FILL TO P900. AT ARRIVAL zo <br />A � 0.. TOP OF FILL TO 70P OF TAMC � 0 <br />// V H. T!S"l':LBY66' TD U+1C <br />lOTTCM OF T1/,,,�}� � <br />f-�f— <br />C fi5I PER iNL11 OF P1b0U(.T <br />MATER IN <br />IE TANK n / TEST HEI(2rT PRESSURE F01tlMA <br />fl. PSI E. F51 NET PS! <br />REMARKS <br />RESULTS <br />HE FINAL TEST PERIOD AS SHOWN ON THE ATTACHED COMIPUTER GENERATED DATA REFLECTS A <br />LOS / GAIN OF:. -.Ott GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/- 00-�Z 90 - <br />THE HORNER EZY CHEK THOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br />FOR TANK INTE I STING. ECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD, THE RESULTS <br />SHOWN ABOVE: ES NOT INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPX STANDARD. <br />INTEGRITY TANK TEST VICES, 41 WEST YOKUTS ST. STOCKTON, CA., 95207, (209) 474-1375 or (800) 262 8379' <br />CERTIFIED TESTER STATE LICENSE 4 _ '��I _ TEST DATE <br />