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AFFQRDA-TF$T Site Name: GEORGE'S MINI MART <br /> 416 2nd Street Address:18662 N. HWY 88 <br /> Galt, CA 95632 City: LOCKEFORD, CA Zip: 95237 <br /> (209) 744-0112 Fax (209) 744-0116 Facility Permit #: N-3466-1-2 CONF# 12-14968 <br /> Date:5/15/12 Time: <br /> Technician: ZANE NIMMO <br /> District Cert #: 0083 Exp. <br /> Healy Cert #: 563743702 Exp. 12/8/12 <br /> Digital Manometer Calibration Date: 4/11/12 <br /> HEADY TEST FORM <br /> Clean Air Separator Pressure Performance Test Nozzle Bag Test <br /> Fuel Grade: ALL <br /> Nozzle Type: 900 <br /> Initial Vacuum/ Pressure prior to test ® - ❑ + <br /> #1 PASS #7 PASS #13 #19 #25 #31 <br /> 1. Initial Vacuum / Pressure (W.C.) 2.00 <br /> 2. Vacuum/ Pressure after i minute, inches of water: 2.02 #2 PASS #8 PASS #14 #20 #26 #32 <br /> 3. Vacuum/ Pressure after 2 minutes, inches of water: 2.02 <br /> #3 PASS #9 #15 #21 #27 #33 <br /> 4.Vacuum J Pressure after 3 minutes, inches of water: 2.04 <br /> 5,Vacuum J Pressure after 4 minutes, inches of water: 2.04 #4 PASS #10 #16 #22 #28 #34 <br /> 6.Vacuum/ Pressure after 5 minutes, inches of water: 2.03 <br /> #5 PASS #11 #17 #23 #29 #35 <br /> 7.Vacuum/ Pressure after 5 minutes, inches of water: 0.80 <br /> ® PASS ❑ FAIL #6 PASS #12 #18 #24 #30 #36 <br /> l declare, under penalty of perjury under the laws of the state of California that based on information and belief formed after reasonable inquiry, the statements <br /> and information provided in the document are true, accurate, and complete. <br /> Technician Signature: <br />