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WORKSHEET FOR SUBMITTAL TO GOVERNMENTAL AGENCY <br /> OWNER/OPERATOR �iL SITE ADDRESS <br /> CZ7Y _ 7'—��L <br /> COUNTY <br /> HAILING ADDRESS <br /> SITE AGENT l-S l 'Z fyL�'"r�� <br /> � <br /> �`l TELEP�HO(NE <br /> ARRIVED TEST SIV$/.-� HOURS TANK LOCATION � � i 7'` PRODUCT <br /> DATE/TIME STORACE FILLED//Z/ LEVEL AT ARRIVAL INCHES BELOW TOP OF FILL NOMINAL TANK SIZEZ <br /> TANK MATERIAL _// APPROX. TANK ACB�YRS. FILLSIZE/TYPE 4 OVERFILL CONTAINMENT TYPE <br /> API GRAVI�.C- AT DEC. F. - API GRAVITY OF�l7�@ 60F - COEFFICIENT OF EXPANSION OF .000 <br /> VISABLE VENTING APPREARS TO BE AT: II L� FILL OPOSITE END, <br /> $AS BURP TUBS, HAS BALL CHECK, UNKNOWN, OTHER <br /> VISA13LE VAPOR TRAPS TO BE BLED: BALL_7CEI�), PIRATORC"' MANWAYS, RETURN LINES, OTHER <br /> PHASE II VAPOR RECOVERY SYSTEM: AIAkSSISTE), L40NG RVN� IEI,LS, MANIFO ID, NONE, OTHER <br /> PUMPING SYSTEM:=Sumoll� TURBINE MAREG! 66//-��/ <br /> ��Yn�'� MODEL PE LINE LEAK Detectors YES, T LL <br /> IC <br /> SIZE Z EST. LINE QUANTITS v`PRODUCT ADDED SV- D SZSTEN_3 SYSTEM TORAL GALLONAGE_ <br /> AMBIENT CONDITIONS: TEMP: PRETEST POSTEST � J SUNt7Y CLOUD <br /> ��``"" NINC„WINDY, BREEZY, NICHT, OTHER <br /> .4 PSI DROA:ac HOURS TEST TO STARD�NOURS PSI TO BE MAINTAINED ON TANK BOTTOM DURING TEST PERIOD 7—SSI <br /> A. GRADE TO TAW OM70M <br /> 1. GRADE TO TANK TOP T` <br /> 6.Pi9AE C. TANK DIA►IETER <br /> D. TEST LEVEL ABOVE GRADE1 <br /> e Ar E. EXTERNAL CROl1ttD MATER 1111OVE TAN[ <br /> SM704 IN. x .0361 PSI <br /> A Z� F. TOP OF FILL TO P00. AT ARRIVAL <br /> C. TOP OF FILL TO TOP OF TANK <br /> C Qy y H. TL3I7.I.87EL'TO'"/OTIUI OF TANI�•�.� z_ <br /> NATER II�lTO//E PSI PER INC" OF PRODUCT «�"' �z�z <br /> E TA NI •.F w / TES�T�HEIGIT PRESSURE FORMA <br /> 1544=_Z—x l - = ¢ <br /> REMARKS: <br /> H. PSI E. PSI NET PSI RESULTS <br /> THE,-Fl AL TEST PERIOD AS SHOWN ON THE ATTACHED COMPUTER GENERATED DATA REFLECTS A <br /> LOSS / AIN OF: _,4�a7t-GALLONS PER HOUR, WITH A 99% CONFIDENCE LEVEL OF +/ roJ gph <br /> THE HORNER EZY CHEK IZ METHOD COMPLIES WITH EPA AND THE STATE OF CALIFORNIA PERFORMANCE STANDARD OF 0.05 GPH <br /> FOR TANK INTEGRITY TESTING. (SECTION 2643 CALIFORNIA CODE OF REGULATIONS) BASED UPON THIS STANDARD THE RESULT <br /> SHOWN ABOVE: DOES DOEST INDICATE AN UNAUTHORIZED RELEASE EQUAL TO OR GREATER THAN THE 0.05 GPH STANDARD. <br /> INTEGRITY TANK TESTING SE ICES, P.O.BOX 691376 STOCKTON, CALIFORNIA, `95269 <br /> (209) 474_1375 or (800) 262 8378 <br /> CERTIFIED TESTER C STATE LICENSE Y yV`lj�[ ,' TEST DATE / L <br />