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WORKSHEET FOR�SUMITTAL TO GOVERNMENTAL AGENCY <br /> OWNER/OPERATOR � �/�� ✓i/=�� � �j[� �/ �'�' SITE ADDRESS /�J c- /�. C L �✓j�fr�� <br /> CITY -- S�-!�/Li COUNTY r+r✓ C /,7 GSL i/✓ <br /> HAILING ADDRESS >� Z� <br /> SITE AGENT /r%�'i�=TrZi�/J� TELEPHONE <br /> ARRIVED TEST SIIC/,�'GHOU�RIS TANK LOCATION /y !L� / PRODUCT <br /> DATE/TDS STORAGE FILLED / Z� A CT LEVEL AT ARRIVAL--3 INCHES BELOW TOP OF FILL NOMINAL TANK SIZE <br /> Z <br /> -7 C«� <br /> TANK MATERIAL ,� APPROX. TANK AG'iZYRS. FILLSIZE/TYPE d OVERFILL CONTAINMENT TYPE 5;�� /J C <br /> API CRA7IT12,k. AT e-- DEC. F. - API GRAVITY OF-'IP;y @ 60F - COEFFICIENT OF EKPANSION OF .000 "7� - COE _4_e <br /> VISABLE VENTING APPRPARS TO BE AT: FILL END, 11ILL7 OPOSITE E ,l HAS BURP TUBE, HAS BALL CHECK, UNKNOWN, OTHU <br /> VISABLE VAPOR TRAPS TO BE BLED! BALL CHECKS, MANWAYS, RETURN LINES, OTHER TI'- y1- <br /> .,�Z7C7`7 <br /> PHASE II VAPOR RECOVERY SYSTEM: BALANCED, ASPIRATOR ASSISTED, LONG RUN WELLS, MANIFOLDED, NONE, THER <br /> PUMP INC SYSTEM: SUCTION, INE HAKE-�� r,�JC��TMODEL/� PIPE/LINE LEAK Detectors( <br /> CHARTED SIZE-� EST. LIFE QUANTITT� PRODUCT ADDED TO FLOOD SYSTEM 4 SYSTEM TORAL GALLONAGE <br /> AMBIENT CONDITIONS: TEMP: PRETEST•5 /JPOSTEST J SUNNY, CLOUDY, RAINING, WINDY, BREEZY, NICA7, OTHER ll=G"�Gy <br /> .4 PSI DRO �AOURS TEST TO STARY'�HOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD /C PSI <br /> A. GRADE TO TAN[ BOTTOM <br /> �41 B. GRADE TO TANK TOP 47 <br /> C. TANK DIAVMR <br /> 6.Pi9.DE <br /> �. D. TEST LEVEL ABOVE GRADE Z� <br /> 41 47 <br /> E. EXTERNAL GROUND MA71?R ABOVE TANK <br /> �7 F- BOTTOM IH. K .0361 PSI <br /> ��j N F. TOP OF FILL TO PROD. AT ARRIVAL ? <br /> A_i 4 • G. TOP OF FILL TO TOP OF TANK �, <br /> IH. TEST:.137EL'TOT lOTTO1 OF TANK <br /> C PSI PER INC" OF PRODUCT <br /> MATER IH, DE <br /> E TANK •..L TEST HEIGHT PRESSURE FOMULA <br /> _L, z C3/ _ <br /> H. <br /> REP(ARKS PSI PSI NET PSI <br /> RESULTS <br /> TRE I T T PE�2IOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS /,,'GAIN OF:.�� GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/— � --Z—' <br /> THE BOBBER EZY CH i;I�?HT�QD COMPLIES WITH EPA AND ':HE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGRgf'T tTIN F,SECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br /> SHOWN ABOVE: � S DOES :1DT/ INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br /> I <br /> INTEGRITY TANK TESTING JE11VI ES, P.O.BOX 691376 STOCKTON, CALIFORNIA, 95269 209) 474-1375 or (800) 2622-x3778 <br /> CERTIFIED TESTER STATE LICENSE 4 it -L,-V 4 TEST DATE <br /> v — <br />