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r r <br /> G WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> 0w?7ER/OPERATOR SITE ADDRESS <br /> CITY �r m GAr--/-C/LJ COUNTY <br /> HAILING ADDRESS <br /> SITE ACENT �Y����� �EU/�Y/LJ�_ TELEPHONE <br /> ARRIVED TEST SItV7 TANK IACAZION PRODUCT ":9A8are <br /> DATE/TIME STORAGE FILLED / PRODUCT LEVEL AT ARRIVAL�INCHES BELOW TOP OF FILL NOMINAL TANK SIZE �OQOa <br /> TANF HATER IAL APPROx. TANK AdL1�/�TRS. FILLSIZE/TYPE OVERFILL CONTAINMENT TYPE +� <br /> API GRAVITY 3� AT DEC. F. - API GRAVITY OF32.T @ 6OF _ COEFFICIENT OF EXPANSION OF .000QS27/ _ COE St�_ - <br /> VISABLE VEITTINC APPRPARS TO BE AT: FILL ILL OPOSITE EITD,a HAS BURP TUBE, �rHAS BALLL CHECK, UNKNOWN, OTRn <br /> VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, MANWAYS, RETURN LINES, OTHER <br /> PRASE II VAPOR RECOVERY SYSTM: BALANCED, ASPIRATOR ASSISTED, LONC RUN WELLS, MANIFOLDED, NO11F THER <br /> PUHPTNC SYSTEM: SUCTICON/, rttrnnrN>i MAKEZ �/� MODEL jj PIPE LINE LEAYES, <br /> K Detector NO, NOT AFPLIC <br /> CHARTED SIZE Q (� EST�—LINE QUANTITY PPMUCT ADDED 7O FLOOD SYSIEH 15`JSYSTEM TORAL CALLONACE <br /> AMBILTTT CONDITIONS: TEMP: PPETEST6'ZPOSTEST SUNNY CLGUDY RAINING, WINDY, BREEZY, NICrRT, OTHER <br /> .6 PSI DRAP1916 HOURS TEST TO STAR{IZA5HOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD 5-0 PSI <br /> Q A. GRADE TO TAN}; SOTTON �Q <br /> 0 // S. GRADE TO TANK TOP -47 <br /> C. TANK DIAJTER <br /> D. TEST LEVEL ABOVE GRADE y <br /> 4(Y / <br /> G B E. ET,TERNAL GROUND MATER ADOYE TAN[ may) <br /> F SC'i7CM IN. K .0361 PSI <br /> F. TOP OF FILL TO PACOD. AT ARRIVAL <br /> A- - C. TOP OF FILL TO TOP OF TANK <br /> H. TT 71.1=70 SOTTON OF TANK _OGo <br /> C <br /> MATER INIDC PSI PER INCH OF PRODUCT <br /> E TANK 4V '+ / TEST HEIGHT PRESSURE FORMICA <br /> 160 Ka?_ <br /> H. PSI F/. PSI NET PSI <br /> REMARKOS¢: <br /> n to <br /> n- u. <br /> RESULTS PERMIT/SERVICES <br /> THE L TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS /CAw <br /> OF- Y_010 GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF SP h. <br /> THE HORNER EZY CHEK II M COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE <br /> FOR TASK <br /> ECTION 243 CALIFORNIACDE OF STANDARD OF 0.05 GPH <br /> SHOWN ABOVE: <br /> ES NOT INDICATE6AN UNAUTHORIZEDORELEASEEEQUALITOSORBGREATEROTHANITHE T0.05RGPHHSTANDARD. <br /> INTEGRITY TANK TESTIN RVICESQ, P.O.BOX 691376 STOCKTON, CALIFORNIA, <br /> �9526/(9A(209) 444-1375 or (80 )) 262 8378 <br /> CERTIFIED TESTER STATE LICENSE N V (JL/� TEST DATE / <br />