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Gasoline Vapor Recovery Test Notification Form

Region:     North         Central          South
Facility Name:  
Facility Address:  
City:  

Facility Permit Number:

  
Date of Test:     

Time of
     Test: 
 
Equipment Startup Date:
Category of Test(s): Start-up Pre-Backfill Inspection
Compliance  
Type of Test(s):
Mobile Fuelers:
Hill-Vac Vapor Return Line Vacuum Integrity
Hill-Vac Fill Pipe Vapor Pressure Fueling
Phase II EVR:
Healy V-R ISD Pressure Sensor
Healy V-R ISD Site Shutdown
Healy V-R ISD Flow Meter
Healy Incon ISD Pressure Sensor
Healy Incon ISD Dispenser Shutdown
Healy Incon ISD Flow Meter
Healy Dispenser Integrity
Healy Liquid Condensate Trap
Vapor-to-Liquid Ratio (V/L)
VR-201/202/209 (Clean Air Separator)
VST Liquid Removal
VST Pressure Sensor
VST V-R Hydrocarbon Emissions
VST V-R Pressure Integrity
VST V-R Flow
VST V-R Thermometer
VST V-R Atmospheric Pressure
VST Hydrocarbon Sensor
VST Processor Activation
VST V-R ISD Site Shutdown
VST V-R ISD Flow Meter
EMCO Liquid Removal
EMCO ISD Vapor Flow Meter
EMCO ISD Vapor Pressure Sensor
HIRT VCS-100 Operability
Nozzle Bag
Phase II:
HIRT-Liquid Removal (G-70-139)
HIRT-Pressure Test (G-70-139)
TP-201.4 (Back Pressure)
TP-201.5 (A/L)
TP-201.6C (Liquid Removal)
Healy Fillneck Vapor Pressure (G-70-187)
Healy Vapor Return Line Vacuum Integrity (G-70-187)
Phase I:
TP-201.1B (Torque Test)
TP-201.1C/D (Drop Tube)
TP-201.1E (P/V Valve)
TP-201.3 (Leak Decay)
TP-201.3B (Leak Decay-Above Ground)
Testing Company:  
Phone Number:  
Your Name:
Your Phone Number:
Your Email Address:
Notes / Comments:

                                

 

 

 

 

 

  Revised 4/26/2012