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Northern Region Office [ ] Central Region Ofrioe ( ] Soulharn Region Oftloe <br /> 4320 KNman Ave., Suite 130 1990 E Gettysburg Avenue 2700 M SL,Suite 275 <br /> Modesto,CA 953669321 Fresno,CA 93726-0244 Bskeref eld,CA 93301-2370 <br /> (209)3374400 (569)790.6960 (061)3266900 <br /> Phase 13 Phase II Gasoline Vapor Recovery Inspection Form <br /> Station Name: e44 07( Gd d; PTO: N- q97-1 - 1 <br /> -- I— <br /> Location: C*, ( r� CKy.. LOW C, Phone#t <br /> Mailing Address: o ;' %4�4 Cit)r. C_v z State: i-1 Zip: <br /> Contact: Title: �� % /-a c c{ c.." <br /> Inspection type: [ )Complaint ( 11" [ )2"d Semi Annual [ 11" [ ]2"d Follow-up To: <br /> Nozzles Inspected(Model and Dispenser Number) '- <br /> Phase 1 System Type: M 2-Point [ ]Coaxial Phase Il System Type: j5f.(Cvy7C <br /> ank Number 1 il! 3 4 Nozzle Number <br /> Product Type - ProductType <br /> Location Nozzle Type <br /> 1. Broken/Missing Vapor Cap 1. Nozzle <br /> 2. Broken/Missing Fill Cap 2. Insertion Interlock <br /> 3. Vapor Cap Not.: ed 3. Check Valve <br /> 4. Fill Cap Not Seated 4. Face Plate/Seal <br /> 5. Vapor Cap Gasket Missing 5. Ring/Rivet <br /> 6. Fill Cap Gasket Missing 6. Bellows <br /> 7. Vapor Adapter Not Tight 7. Bellows Clamp/Wire <br /> 8. Fill Adapter Not Tight s. Swhret(s) <br /> 9. Dry Break Gasket Deteriorated 9. Hold Open Latch <br /> 10. Gasket Between Adapter And 10. Hose <br /> Fill Tube Missing/Not Seated 11. Hose Configuration <br /> 11. Coaxial Fill Tube Spring 12. Uquid Removal Sys. <br /> Defective 13. GPM <br /> 12, Pressure Vacuum Relief Valve J Incinerator Function ( ]System Pressure [ ]Signs Posted (X=Deficiency) <br /> 13. Other. KEY FOR DEFICIENCIES <br /> Tank Depth AD=Ad]ustment, B=Broken, F=Flat, FR=Frayed, K=Kinked, L=Long, LO=Loose, <br /> Fill Tube Length M=Mbaing, MA=Misaligned, NC=Not Csrtdied, S=Short, TO=Tom <br /> Difference(13"or less) ' Inspection Result <br /> Phase I Report Check marks Indicate component Phase II Report 7=repair within 7 days, T=Tagged out of order until <br /> de"r,C.(fic�i"e�ncies J repaired,U=Taggabie violation corrected during inspection <br /> Comments: 1'LtL�cy I'IuS at-1 ogg"at W o"'ej C&a4L4--1 /0lnu5--,C .r cf r�r; rJRlo/ A fr,,��,� Gfrc <br /> f«Ilk_S <br /> va-l."e C4) l !J�-�'a^ A�t.ZC4 S kc �� lh�E cE' i r r .r,s �{. fr ,r >11�r, c 7` <br /> R <br /> Inspector: t= E�^r� Date: -7�1a���.� Received`BK1 <br /> When repair are complete call: ( ) <br /> Warning: Items checked above in the Phase I portion of the inspection form and items coded with a"T"or"U"In the Phsae It <br /> Inspection results category are In violation of San Joaquin Valley Unified Air Pollution Control District rul*as The <br /> California Health 3 Safety code specifies penalties for each day of violation. <br /> Note: CA Health&Safety code Section 41950.2(e)requires that the above listed 7-day deficiencies be repaired within 7 days. <br /> Failure to do so will result In legal action. <br /> lava UW <br />