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r " <br /> WORKSHEET FOR SUMITTAL TO GOVERNMENTAL AGENCY <br /> O41NER/OPERATOR <br /> SITE ADDRESS l <br /> C I TY c0UNTv <br /> HAILING ADDRESS <br /> SITE AGENTT � / TELEPHONE <br /> ARRIVED TEST SI7iV��5R0URS TANK LOCATION /V E r� z #3 PRODUCT_ <br /> DATE/TIRE STORAGE FILLED 140-14 RODUCT LEVEL AT /ARRIVAL d INCHES BELOW TOP OF FILL NOMINAL TANK SIZE <br /> TANK MATERIAL .�C.� APPROX. TANK AGVI Xrn. FILLSIZE/TYPE_'OVERFILL CONTAINMENT TYPE <br /> API GRAVITY 31• AT -5 -tEG, F. - API GRAVITY OF32e/ @ 60F - COEFFICIENT OF EXPANSION OF .000 Q5�� - COE _�J <br /> VISABLE VENTING APPRZP.ARS TO BE ATI ILL Etm FILL OPOSITE END, RAS BURY TUBE, HAS BALL CHECK, UNKNOWN, OTHFR <br /> VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, HANWAYS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY SYSTEM: BALANCED, ASPIRATORASSASSISTED, LONG RUN WELLS, HANIFOL.DED, ON , OTHER <br /> PUMPING SYSTEM:�SSUCCTI/ON, TURBT HAKE �C,e� fHODEL PIPE LINE LEAK Detector YES NOT AYPLTC <br /> CHARTED SIZE ?%a fW EST. LINE QUANTITY PRODUCT ADDED TO FLOOD SYSTEM 5- SYSTEM TORAL GALLONAGE /--*'G'C>z, <br /> i <br /> AMBIENT CONDITIONS: TEMP: PRETESTPOSTEST�> CLOUDY, RAININC, WINDY, BREEZY, NICHT, OTHER <br /> .4 PSI DRC��ROURS TEST TO START��O)CHOU'R`S PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD -- PSI <br /> A. GRADE TO TANK BOTTOM <br /> CLT_ B. GRADE TO TANK TOP 4 <br /> C. TANK DIAVMR J <br /> 6•Pi4AE / <br /> ! D. TE.ST LEVEL ABOVE GRADE ! <br /> GB E. EXiERNEXTERNAL GROUND WAT RKABOVE <br /> O E TAN T <br /> F. TOP OF FILL TO PROD• AT ARRIVAL O <br /> A 1L C. TOP OF FILL TO TOP OF TANK <br /> H. TLSF:.L M'TO'BOTTOH OF TANK <br /> MATER INSIDE C PSI PER INCH OF PRODUCT <br /> TANK a / TEST HEIGHT PRESSURE FOPlIULA <br /> E <br /> REPIARKS N. PSI E. FSI NET PSI <br /> RESULTS <br /> HE FINAL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFI,EC"I'S A <br /> OS / GAIN OF.-,.DJ6 GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF gph, <br /> THE HORNER EZY CHEK I OMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTE�EDOES <br /> TING. (S CTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br /> SHOWN ABOVE: NOT NDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GFH STANDARD. <br /> INTEGRITY TAN ICES, P.O.BOX 691376 STOCKTON, CALIFORNIA, 95,269i(209) 474-1375 or (800) 262-8378 <br /> 2, <br /> CERTIFIED TESTER J STATE LICENSE N ✓ TEST DATE <br />