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Facility Name: IVERIZON-111YON RSU <br />D. Tank Top/Associated Hardware: General Notes <br />Dipstick: YES <br />Annular Space Lid/Cap/Seals: 1OK <br />Manhole Street Lid-Bolts/Seals: N/A <br />Manhole Ports/Seals: N/A <br />E. Fill Buckets: General Notes: <br />Lid/0-Ring: <br />Report Number: Iil,-051 S_004 I Date] <br />Tank I Tank 2 Tank 3 <br />Drain Valve: <br />OK <br />Cap -O -Ring: <br />OK <br />Cap Adaptor: <br />OK <br />Drop Tube: <br />N/A <br />Mechanical Overfill Valve: <br />N/A <br />Striker Plate Confirmed? <br />N/A <br />F. Sumps/Annular/Trenches: General notes: <br />General Cleanliness: <br />OK <br />Sump Riser/Tank Collar Connection penetrations: <br />N/A <br />Sump Shields/Water Tight Lids/"Hat"or "Plugs"? <br />N/A <br />Piping Visual Inspection: <br />OK <br />Conduit, J Box, Seal Offs, Inspection: <br />OK <br />Probe/Cap Wire Condition: <br />OK <br />In Tank Water Eliminator: <br />N/A <br />G. Dispenser. <br />N/A <br />I <br />Pump 1 <br />Dispenser Pan <br />Dispenser Piping: <br />Dispenser Impact Valve Location and operation <br />Nozzle Condition and Operation: <br />Nozzle Hose Condition and Operation: <br />Hose Retractor Condition and Operation: <br />Does Emergency shut off switch work? ( Refueling Site Only) <br />Is The Electronic In -Line Leak Detector Present and Tested? <br />Does Turbine Shut Down if System Detects a Leak? <br />Does Positive Shut Down Occur If Monitoring System is Turned Off? 7NIA <br />Slab Condition: OK Notes: <br />Traffic Condition: NONE Notes: <br />Rain/irrigation Run Off: NONE Notes <br />Photos Taken? NO Notes: <br />Monitoring Equipment Certified? YES Notes: <br />Certified tester's I D#: 1546025990 <br />Pump 2 I Pump 3 <br />07.2004 <br />Tank 4 <br />Pump 4 <br />Signature Of Certified Technician: � `� Testing Company: Sunwest Engineering Constructors, Inc. <br />Printed Name Of Technician: RUDY ALM LAN Telephone: 562-663-1319 <br />All Certification Data Must Be Attached To Verify Above Information <br />