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Work Order: 2263724 <br /> (MO)R(ESV)Testing Fonn-version 1.101/8/2011 <br /> Emergency Shut Off (ESO) & <br /> Dispenser Emergency Shutoff Valve (ESV) <br /> ANNUAL TEST RECORD LOCATIONS AND TEST DATA <br /> k <br /> ng TANKNOLOGY n Date• <br /> tion Name• aQ'/ Store#: State ID#:ress: / A City: State: <br /> Emer c Shut Off ESO Testin Results <br /> On / /D in accordance with"ESO Vendor Letter(3-21-05).doe", from Retail Compliance <br /> Dep ee <br /> nt,as a part of annual compliance testing,this representative tested the Emergency Shut Off <br /> ESO switches indicated on this sketch Findin s listed below <br /> Emergency Shut Off(ESO) If No,Provide <br /> Operational? N Maintenance Log If Date Called <br /> Dispense mergency Shutoff Valve ESV Testing Results <br /> On OO /� in accordance with NFPA 30A this representative tested the automatic-closing feature <br /> of the ITispenser Emergency Shutoff VALVE(S)(ESV) located in the supply lines at th base of each <br /> individual island type dispenser indicated on the diagram below. Each device(#) in all, <br /> would automatically close. Findings listed below: <br /> Disp.Emergency Shut Off IIf No,Provide <br /> Valve(ESV)Operational? N Maintenance Log#__L_ <br /> Da[e Called <br /> Site Map Of Lavation and Placement of Devices"1"ened: <br /> C•sfi.a <br /> E� <br /> Sitrinature0fRepresen e: <br /> Tanknology Inc. 11000 N. MoPac Expressway, Suite 500,Austin,Texas 78759 <br />