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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL kwENCY <br /> OWNER/OPERATOR J/ ✓' C�l•,j;/�lL� :fly ! i Ss <br /> SITE ADDRESS <br /> CITY <br /> COUNTY <br /> HAILING ADDRESS 7 Z C ��. <br /> SITE AGENT �.l A ��, . /�_ TELEPHONE C52��) �1 �5 �'4 <br /> ARRIVPD TEST SIr JGHOURS TANK LOCATION PRODUCT <br /> DATE/TIME STORAGE FILLED L/LJ /19ODUCT LEVEL AT ARRIVAL �/INCRES BELOW TOP OF FILL NOMINAL TANK SIZE <br /> y - <br /> TANK MATERIAL = �rAPPROE. TANK AGER` YRS. FILLSIZE/TTPE 4- OVERFILL CONTAINMENT TYPE <br /> API GRAVITY 35 AT DEG. F. - API GRAVITY OF— � B 60F - COEFFICIENT OF EXPANSION OF .000 COE 4 �L <br /> VISABLE VENTING APPREARS TO BE AT: FILL END,, ILL OPOSITE ENDN. HAS BURP TUBE, HAS BALL CHECK, UNKNOWN, OTHER <br /> VISABLE VAPOR TRAPS TO BE BLED: BALL CHECKS, MANWAYS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY SYSTEM: BALANCED, ASPIRATOR ASSISTED, LANG RUN WELLS, MANIFOLDEDNONE, 0 ER <br /> PUMPING SYSTEM: SUCTION, PIPE LINE LEAK Detecto YES, NOT APPLIC <br /> CHARTED SIZE e7l EST. LIRE QDANTIil� PRODUCT ADDED TO FLOOD SYSTEM 59YSTEM TORAL GALLONAGE /CC O <br /> AMBIENT CONDITIONS: ISZY <br /> S: T : PRETEST SI rosTEST SUNNY, CLOUDY, RAINING, WINDY, BREEZY, NIGHT, OTHER <br /> JOP <br /> .4 PSI DROHOURS TEST TO START//TOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD S[Y�j PSI <br /> A. GRADE TO TANI BOi'!ON ��`C <br /> O yti D. GRADE TO TANK TOP 5- <br /> C. <br /> C. TANK DIAMETER <br /> 6.Pi?AE <br /> ! D. TEST LEVEL ABOVE GRADE <br /> •L B � E. EXTERNAL GRDUND MATER ABOVE TANK <br /> �7 F IOTYOM IN. K .0361 PSI - <br /> F. TOP OF FILL TO PROD. AT ARRIVAL Z� <br /> A G. TOP OF PILL TO TOP OF TANK <br /> ` H. TES 7JJMEL'TO'IOTTON OF T <br /> DE CPSI PER INCH OF PRODUCT <br /> �VATERINSI <br /> f TEST HEIGHT PRESSURE /FORMULA >G <br /> X <br /> REIIARKS: <br /> —fsFl PSI NET P51 <br /> ! PSI <br /> RESULTS <br /> THE FINAL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOS / GAIN OF+<C; GALLONS PER HOUR, WITH A 997. CONFIDENCE LEVEL OF +/— e07/ gph, <br /> THE HORNER EZY C_ HOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGIt Y T FSECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br /> SHOWN ABOVE: DOES (?0. INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 CPA STANDARD. <br /> 'I <br /> INTEGRITY TANK TEST V C O.BOX 6913T6 STOCKTON, CALIFORNIA, 95269 (209) 474-13T5 or (800) 2628378 <br /> CERTIFIED TESTER STATE LICENSE M (` •� yTEST DATE ' 2T./ <br />