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RELEASE EVALUATION CHECKLIST <br />S/S #: Business Name. <br />Address: <br />Tank #: Capacity. <br />Product: <br />Date & Time Allowable Variation was Exceeded: <br />CHECK OFF EACH STEP AS IT IS COMPLETED. <br />STEP i <br />STEP 2 <br />STEP 3 <br />STEP 4 <br />STEP 5 <br />STEP 6 <br />L <br />I•ill out this form <br />wManever the <br />allowable varictio <br />is exceeded and <br />send in with the <br />Quarterly Report. <br />RECORDS REVIEWED Date/Time: Should be done <br />Performed by: within 2 hours. <br />NEW RECONCILIATION <br />Date/Time: <br />Should <br />be <br />done <br />PERFORMED <br />Performed by: <br />within <br />24 <br />hours. <br />DISPENSER METER Date/Time: Should be done <br />CALIBRATION CHECKED Performed by. within 3 days. <br />(COMPLETE TEST REPORT) <br />STEP 7 (-1 HYDROSTATIC PRESSURE Date/Time: Should be done <br />(—J TEST PERFORMED ON PIPING Performed by: within 4 days. <br />PRECISION TANK TEST <br />Date/Time: <br />Should <br />be done <br />PERFORMER <br />Performed by. <br />within <br />5 days. <br />�j ADDITIONAL <br />INVESTIGATION <br />Date/Time: <br />Should <br />be done <br />UU PERFORMED <br />AS REQUIRED <br />Performed by: <br />within <br />5 days. <br />Briefly <br />i <br />I hereby certify this is to be a true and accurate report. <br />Dealer's Signature: Dote, <br />