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17 <br /> GDF Name and Address: Testing Firm Name and Address: <br /> Healy V/L Field Data Sheet <br /> Tee Connection Test Result (6.1) ft3 <br /> Date of Last Gas Volume Meter Calibration <br /> Gas Volume Meter Correction Factor(9.3) <br /> Pressure Measurement Device Calibration Date <br /> Phone No. ( ) <br /> Test Date>Tme: Test Performed by: <br /> If Required by local district, provide <br /> Technician Certification Number: <br /> Certification Expiration Date: • <br /> Pre-Test Leak Check: District Test Witness - <br /> Initial/Final Pressures, in. H20 _/__ Applicable ARB Executive Order(circle one) <br /> Post-Test Leak Check: A/C # _ P/O# <br /> Initial/Final Pressures, in. H2O _/_ VR-201 or VR-202 <br /> Allowable V/L Range 0.95-1.15 <br /> 7.7.1 7.7.2 7.7.3 Initial Final 7.7.8 9.2 7.9 7.8,7.9 <br /> Total Gas Dispensing Initial Final 7.8, 9.1 or 7.10 <br /> Nozzle Dispenser Dispenser Time, Meter Meter V/LAverage Pass or <br /> Pump Fuel Pumped, Rate, V/L <br /> # Grade Serial# Totalizer, Totalizer, Gallons Seconds gpm Reading, Reading, (if necessary) Fail <br /> • <br /> Healy Model 900 Nozzle V/L Test Procedure„ Exhibit 5—Executive Orders VR-201-D and VR-202-D <br />