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76 PRODUCTS COMPANY <br />2929 East Imperial Highway <br />Brea, California 92621 <br />ANNUAL SITE INSPECTION FORM <br />SITE #: 4/ya / <br />I <br />DATE: S'l-?JC <br />1. VAPOR RECOVERY <br />Stage I (Fill area) <br />Stage II (Equipment) <br />System Type <br />Hose/Nozzle Type <br />Co -axial <br />_ Dual <br />Remote <br />Balance <br />Assist <br />Co -axial <br />_ Dual <br />Bootless <br />COMMENTS <br />PMENT S U NIP PROB.SYS. <br />Cover <br />Cap - - <br />Fill Seal <br />over <br />Cap <br />Seal <br />Drybreak <br />Pump Cover X - - <br />/Pump — — <br />p Sump Area ZC _ <br />r Spill Box _ X <br />p Tube <br />k Bot. Prot. - - <br />Y N PROB:SYS. <br />rfill valve installed <br />p Tube within 6" of <br />ank bottom <br />LJJJ.DISPENSERS <br />COMMENTS: <br />AIL - <br />SPENSERS S <br />General Insp. <br />Blending Unit <br />Impact Valves <br />Hoses & Nozzles <br />Type of monitoring system <br />N_wrnm <br />U N/P PROB.SYS. <br />_ _ <br />(if present): <br />COMMENTS: - <br />0VVQrMT Y=YES <br />N=NO PROB.SYS.=PROBLEM SYSTEM <br />S=SATISFACTORY U=UNVJ 110Dtll.1Vh1------ <br />COMMENTS: <br />This form shows the conditions of the site after the technician has left the <br />site. Copyright 1995, Triangle Environmental Inc. <br />