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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> MIER/OPERATOR �TiE.v �i(J/iC/� j� D`J f SITE ADDRESS /4SZ <br /> CITY COUNTY <br /> MAILING ADDRESS <br /> SITE ACETTTJfI.�L � J/,LtJD� TELEPHONE [�/ ) /✓J S��¢� <br /> ARRIVED TEST SIT{7/'�75 TANK LOCATION ��� f�'�O � __PRODUCT <br /> DATE/TIME <br /> DATE/TIME STORAGE FILLED 5 PRODUCT LEVEL AT ARRIVALS�INCTIES BELOW TOP OF'FILL, NOMINAL TANK SIZE <br /> 7A1IF MATERIAL APPROJC, TANK AG4,114YRS. FILLSIZE/TYPE `Y OVERFILL CONTAIfDMTT ME <br /> API GRAVITYy AT DEC. F. - API GRAVITY OF t�•/ @ 60F - COEFFICIENT OF ERPANSION OF .000 �O/Z� - COE 7 <br /> VISA-BLE VENTINC APPREARS TO BE AT:<fnl , FILL OPOSITE EI RAS BURP LTJB HAS BALL CHECK, UNRTOS717, OTHF1t <br /> VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, HANWAYS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY SYSTEM: BAIANC ,,rr ASPIRATOR ASSISTED, LO� MANIFOLDED, NONE, OTHER <br /> PUMPING SYSTEM:(SUCTIO)7 TURBINE MAKE K/ MODEL PIPE L per( Detectors YES, NOT APPLiC <br /> , T <br /> CHARTED SIZE &1;7Z EST. LINE QUANTITT � PRODUCT ADDED TO FT,OOD SYSTEM,3 SYSTEM TORAL GALLONAGE ��Q <br /> AMBIENT CONDITIONS: TEMP: PRETESTS�7POSTEST SUNNY CLOUD NING, WINDY, BREEZY, NICHT, OTHER <br /> .4 PSI DROP/$,-%OHOURS TEST TO STAR7/7Jt�-'ROURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD ��d FSI <br /> rJ R. GRADE TO TANK BOTTOM <br /> / B. GRADE TO TANK TOP 7� <br /> C. TANK DIAMETER �Z— <br /> G.Qi9.DE <br /> �._!• —� D. TEST LEVEL ABOVE GRADE Z 7 <br /> .1•• I .�JiCD ( 8 E. EXTERNAL GROUND MATER ABOVE TANK <br /> �7 <br /> F1 <br /> / •!�/��. BOTTCH IN, K .0361 PSI <br /> I/•J / F. TOP OF FILL TO PI00. AT ARRIVAL _ 3Q <br /> A G. TOP OF FILL TO TOP OF TANK' <br /> H. TLST71IMEL'TOBOTTCH OF TANK f r Z <br /> MATER INSItC C PSI PER INCH OF PRODUCT <br /> -� <br /> E TANK " TEST HEIGIIT PRESSURE FOP?#1LA <br /> yy /ZiOPT z cy6/_ - o_ = U� <br /> REMARKS: H. PSI y S NET '�PsSI <br /> Ld „a <br /> IAR <br /> ENy►Rnn(rncr�lrAl <br /> Fl-- I YF4TH <br /> PERMIT/SERVICES <br /> RESULTS <br /> THE FINAL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOS / GAIN OF:,, GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF ) gph, <br /> THE HORNER EZY CHEK COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEL Y ING. ( ECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br /> SHOWN ABOVE: OES NOT INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br /> INTEGRITY TANK TE VICES, P.O.BOX 6913T6 STOCKTON, CALIFORNIA, 95269 (209) 4T4-1375 or (800) 262 378 <br /> CERTIFIED TESTER STATE LICENSE d TEST DATE <br />