Laserfiche WebLink
r <br /> Northern Reglon OfflCe O Central Region <br /> 4320 IUernanAve„Sots 130 129D E.Qattpburo renue ( ) Southam Rspon Office75 <br /> Modesto,CA 95356-2321 Freesia,CA 93726-0244 Saco ef odSt. 3ulh 330 <br /> (200)5574400 (568)230.5= 8ekerefterd,CA 233012770 <br /> (209)32"2pQ <br /> Gasoline Vapor Recovery inspection Form <br /> Station Neow.. �.-'1 r , <br /> Location: J j )4,A e, _.L r City; L Phone 9)t S ;I',- <br /> Contact <br /> I„Contact: Tito: <br /> Source Test Company l ,` i , r 1.. Technician: _Z Phone 0, 77"/ <br /> Inspection Type: fsc)Inlbol Test t ( )Ratsrit. (]Start Up Start Up Date Test Due Date: <br /> Phase I Systern Type: k)2-Point ( )Coalxlal Phase 11 System Type- 6- 7� - i '� 4 m Number of No¢ies <br /> Tank Number 1 2 3 4 Nozzle Number <br /> Product Type- Product Type <br /> Location Nozzle Type <br /> I. 8rokordMissinj Vapor Cap 1. Nozzle <br /> 2. t rokenlMiseing Fill Cap 2, Insertion interlock <br /> 3. Vapor Cape Not Seated 3. Check Valve <br /> 4. Fig Cape Not Seated 4. Face Plate/Seal <br /> 5. Vapor Cap Gasket Missing S. RInWRivet <br /> 6. Fill ltxp ekat Missing . Bellows <br /> 7. Vapor Adopter Not Tight 7. Bellowo Clomp/Wire <br /> 8. Fill Adeptar Not tflht 8. Swivels) <br /> P. Dry Break Gasket 0storlorated 19. -Nold.OpenLatch <br /> 10.Gasket Between>*dapter Ana 10. Hose <br /> Fill Tube MissinpMot'L4eatad 11_ Hose Configuration <br /> 11.Coaxial Fill Tube Spring 12, liquid Removal Sys. <br /> Defective 13. GPM <br /> 12. Pressure Vacuum Relief Valve Incinerator Function [ )System Pressure ( }Blgns Posted (X=DeflclenW <br /> Tank Size KEY FOR.DEFICIENCIES <br /> Tank Depth AD wAoustment, B-Broken, F=Flat, FR-Frayed, KaKhksd, LaLanQ, Lb_Looee,. <br /> Fill Tube t:e ogth M■Missing. MA,Misaiipnod, NC-Nat Certified, S-Short;`TfMom <br /> Difference(8"or Leas) Inspection Result <br /> Phase I Report: Check marks Indicate component Phase 11 Report 7=repair within 7 days, T=Tagged out of order until <br /> deficiencies ro aired U=Te able violation corrected during ins lion <br /> Source Test <br /> Skene Pressure intagrity Teat( ST-3d). [ Paas )Fall Final Reading: N o Ullage(s): 1 I Llm>x(s): E, 7 <br /> Dynamic tack Pressure Teat{ manes 11=a I 12OW ae <br /> Air to Uquid Volume Ratio Test(All)) ( ]Pass__I.[ ]Fall j Tagged Nozzles <br /> [ Red Jacket System Cslibretion ( )Healy Vacuum Test(G-70-70 Ex 5) ( ]Hirt Vapor Leak Te5t(G-70-138) ( }Pass [ ]Fall <br /> Comments: /` 55 r J J l�@ ST- 3� fl "rhe �- <br /> r,' jv u8' X0.6. ere- in r4±-1 Ter <br /> N o„ <br /> BQ u ; i e c' ; a � r1 The 5 >4�� i or ue rtST oyl 6JA T.fiks . <br /> Ins entor: To P r1 2 ? - - r <br /> p �! �V-; 1��).. Date: tG"" Received By: <br /> When repairs are complete cell (t'__r ) 4 7 �n ff <br /> Waming: lbsm checked above In the Phase I portion of the Inspection form,items coded with a"T"or"U"in the Phase 11 <br /> Inspection results catagory and Source Test fallures ars In violation of San Josquln Valley Unified Air Pollution Control <br /> District rule(s). The California Health if.Safety Code specifies penatti:rior such day of vlolatlon. <br /> Note: CA.Health&Safety Code section 411960.2(e) hat the above Ilsta417-day Mflplenclse be rapaired within T days. <br /> Fallure to do so will result in legaal'a7ctlon7.j <br /> 9ounceTost4)pP <br /> S1,,,LrJ Scl, �d�,�, <br /> B 'd 3SW d6;3 :01 60 01 .add <br />