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y <br /> U NO CALG,' TO BE COMPI= LEER <br /> AUSMRT.R `MPEAT' ION IS EXCEIDID <br /> AND SRU IN WnM QUAF=ff REPORT <br /> r . <br /> RELEASE EVALUATION <br /> CHECKLIST <br /> Facility Name: <br /> Tank t#: Sizer Product <br /> The allowable variation Was exceeded. Date/Time: <br /> Check off each step as it Is completed. If completion of any of the steps <br /> reveals the reason for exceeding the allowable variation it is not necessary <br /> to complete the remainder of the- ateps. <br /> Step 1 ❑ Re=ds Rttiemed date/time: Should be done <br /> Perf%A byt within 2 hours. <br /> Step 2 ❑ Nev Reconciliation Perfarmed DateMme: Should be done <br /> Perforeed by: within 24 hours. <br /> Step 3 ❑ Taal Ovw Notified Date/Time: Should be done <br /> Perforw by: within 24 hours. <br /> Step 4 ❑ Records Retieaed from last Static Date/time: Should be done <br /> Situation (Rust be performed by Performed bTt within 24 hours. <br /> qualified persoa.i <br /> Step 5 ❑ facility Pbysically tnapected for Date/Timet Should be done <br /> Evidence of Leaks Performed by: within 2 days. <br /> Step 6 ❑ Calibration on Dispenser Meters Date/Timet Should be done <br /> CQected CCbrplete Mktg Calibration Performed br: within 5 days. <br /> Chea Fbrml <br /> Step 7 ❑ hydrostatic Prew a Teat on Pipiaq Date/Time: Should be done <br /> Performed Permk by. within 4 days. <br /> Step 8 ❑ 'Precision Tank Test Performed Date/Timet Should be done <br /> Pek'forsed by: within 5 days. <br /> step 9 ❑ lbdditional iaeestigation ferforaed as . Date/Timet Should be done <br /> required by Performed b1t within 5 days. <br /> Describe briefly the reason the allowable ♦Arlgtion van exceededr <br /> 1 Hereby Certify this to be a 'true and Accurate Report . <br /> Signature/Dater <br /> kttach this report to Form B, C, or D Wbece Womble rariatloo +ns esreaded. Wage 12E <br />