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A <br />AVR-201/202 <br />Healy Nozzle Bag Test Report <br />Permit Number: <br />Test Company: BZ SERVICE STATION MAINT <br />Site Name: ECONO GAS <br />Technician: ED STEARNS <br />Site Address: 880 VICTOR ROAD <br />Certification Number Expiration Date <br />City: LODI Zip: <br />District: <br />Dats/Time of Test: 8-10-09 <br />Franklin (Healy): 114793161 <br />1 declare, under penalty of perjury under the laws of the state of California that based on information and belief <br />formed after reasonable inquiry, the statements and information provided in the document are true, accurate, <br />and complete. <br />Signature of Technician: Date: 9 •1 d "dI <br />V002 MQI,LV,LS EMAHaS ZS 08CZ TLC 9T6 XVJ CT:OT OTOZ/80/TO <br />NOZZLE BAG TEST <br />Nozzle Number <br />Gasoline Grade <br />Nozzle Type <br />Collapse es/No <br />1 <br />ALL <br />HEALY 900 <br />N <br />2 <br />ALL <br />HEALY 900 <br />N <br />3 <br />ALL <br />HEALY 900 <br />N <br />4 <br />ALL <br />HEALY 900 <br />N <br />5 <br />ALL <br />HEALY 900 <br />N <br />5 <br />ALL <br />HEALY 900 <br />N <br />7 <br />ALL <br />HEALY 900 <br />N <br />8 <br />ALL <br />HEALY 900 <br />N <br />[To=talNurber of Nozzles <br />Number of Nozzles Tested <br />Number of Nozzles Passed <br />1 declare, under penalty of perjury under the laws of the state of California that based on information and belief <br />formed after reasonable inquiry, the statements and information provided in the document are true, accurate, <br />and complete. <br />Signature of Technician: Date: 9 •1 d "dI <br />V002 MQI,LV,LS EMAHaS ZS 08CZ TLC 9T6 XVJ CT:OT OTOZ/80/TO <br />