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Q <br /> Record of Computer Chaneaange, or Calibration <br /> El COMPUTER CHANGE *CALIBRATION P Change, <br /> M <br /> SHELL 0 <br /> METER CHANGE '❑W/M NOTIFIED <br /> i <br /> STATION STREET ADDR SS / _ CITY / TE <br /> �� <br /> WIC NO.:/ DEALER: t <br /> {/ N p-4,21-5 <br /> \1-S <br /> _Ne't G <br /> _ PUMP-MAKE AND MODEL SERIAL NUMBER ATION <br /> �, I,�' �� (_ ? ( 1� ) ✓ I (- �/ CHE ADJUSTED TO <br /> MONEY GALLONS FAST SLOW FAST SLOW <br /> TOTALIZER FINISH <br /> READINGS MONEY GALLONS / TOTALIZER SEALED METER SEALED <br /> START �' O YES (3 NO O,VES C) NO <br /> PRODUCT 1 i i GALLONS RETURNED TOaSTORAGE JOLD SEAL NO. NEW SEAL/NO' <br /> PUMP-MAKE AND MODEL' SERIAL NUMBER CALIBRATION ✓ <br /> CHECKED ADJUSTED TO <br /> MONEY V GALLONS FAST SLOW FAST SLO <br /> TOTALIZER FINISH <br /> READINGS MONEY GALLONS TOTALIZER SEALED METER SEALED <br /> START YES NO Q�ES NO <br /> PRODUCT RETURNED TO STORAGE OLD SEAL NO. NEW SEAL NO <br /> II PUMP-MAKE AND MODEL SERIAL NUMBER CALIBRATION <br /> I <br /> . � �� ! t . ,. J ( > >, !r l��. qtr,.% 1!;?��- �. � <'• .!)� {i �:'.1`�� CHECKED ADJUSTED TO <br /> " MONEY GALLONS FAST SLOW FINISH FAST SLOW <br /> 11 - <br /> TOTALIZER 1 ) Lt`V 1 e <br /> READINGS MONEY GALLONS TOTALIZER SEALED METER SEALED <br /> START !1 6' ? 3 C]YES NO 0,Y/ES NO <br /> r / <br /> PRODUCT I'I GALLONS RETURNED TO STORAGE OLD SEAL NO. NEW SEAL lyO. <br /> PUMP4MAKE AND MODEL SERIAL NUMBER (/. _/ CALIBRATION <br /> CHECKED ADJUSTED TO <br /> MONEY GALLONS . FAST SLOW FAST _)TW <br /> FINISH <br /> TOTALIZER � <br /> READINGS MONEY GALLONS TOTALIZER SEALED METER SEALED <br /> START /I /; '(J C]YES [3INO OYES ONO <br /> PRODUCT / I GALLONS RETURNED TO STORAGE OLD SEAL NO. NEW SEA4 NO- <br /> PUMP-MAKE AND MODEL SERIAL NUMBER CALIBRATION vv <br /> CHECKED ADJUSTED TO <br /> MONEY GALLONS FAST SLOW FAST SLOW <br /> FINISH <br /> TOTALIZER <br /> READINGS MONEY GALLONS TOTALIZER SEALED METER SEALED <br /> START ❑YES [3 NO OYES O NO <br /> PRODUCT GALLONS RETURNED TO STORAGE OLD SEAL NO. NEW SEAL NO. <br /> PUMP-MAKE AND MODEL SERIAL NUMBER CALIBRATION <br /> CHECKED ADJUSTED TO <br /> MONEY GALLONS FAST SLOW FAST SLOW <br /> FINISH <br /> TOTALIZER <br /> READINGS MONEY GALLONS TOTALIZER SEALED METER SEALED <br /> START OYES O'NO OYES ONO <br /> PRODUCT i ETURNEDTOSTORAGE OLD SEAL NO. NEW SEAL NO. <br /> MAINTENANCE COMPANY / <br /> ` <br /> ;T <br /> DEALE�'S SFGNATURE 1 / MAINTENANCE MAN'S,SIGNATURE <br /> SR-80-03 COPY DISTRIBUTION: 1 &4 ADMINISTRATIVE OFFICE;2 DEALER;3 CONTRACTOR <br />