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f� g 77 <br /> ■ fcLeSl <br /> 2017 <br /> Self Inspection Checklist: Healy VR- 201/202 EVR Phase 11 Month: e <br /> and 2-Point Phase I Vapor Recover t„ �..... HEALTH Year: g <br /> p y a <br /> Site Name: <br /> Address: <br /> Inspection frequency: Five(5)days per week, unless throughput is less than 25,000 gallons per month then weekly inspections are required. <br /> Instructions: Place a check mark(. ) in each box if no problem is found. Mark with an"X"any box if a problem is found. Record any problems in your repair log. Keep these <br /> records in your Operations and Maintenance manual for five(5)years. See the reverse side of this form for more information. <br /> Day of the Month <br /> 1 10 11 12 13 14 15 16 17 18 19 0 1 2 3 4 5 6 7 8 9 0 1 <br /> Tanks area Phase I Vapor Recover <br /> 1. PV valve—Present. No debris. Check for shadows. <br /> 2. Spill container—Clean and dr <br /> 3. Spill container valve—Closed, not damaged. <br /> 4. Fill adapter—Tight on riser, swivels properly. <br /> 5. Adapter caps—Tiht, gasket present, no damage. <br /> 6. Fill tube—present OPINack screw assembly tight <br /> 7. Vapor adapter—Tight on riser, poppet aligned/not <br /> damaged, and swivels properly. <br /> 8. Vapor cap—Tight, gasket present. <br /> Dispenser Area Phase II vapor Recover <br /> 9. Air District decal—Present w/correct toll-free number <br /> 10. Hose—EVR-certified, no kinks or visible wire strands <br /> 11. Nozzle--Healy 900, spout not loose or misaligned <br /> 12. Hold open latch—Present, in good repair <br /> 13. Latch ring—Present, in good repair <br /> 14. Bellows and faceplate—Present, in good repair <br /> 15. Breakaway—Present, EVR-certified, no leaks <br /> 16. Retractor—Operates properly, in good repair <br /> Weekly Inspection: _ <br /> 17. Insertion interlock mechanism—o erates properly <br /> 18. Test VP-1000 pump for normal operation <br /> Quarterly Inspection <br /> Inspect VR-1000 pump piping: (date) Check dispensing rate: (date) <br /> Check Clean Air Separator for proper ball valve position: Ball valve A: open/closed Ball valve B: open/closed <br /> Ball valve C: open/closed Ball valve D: open/closed <br /> Inspector's Initials: I T771 1 11 1111 11 11 11-FI -TI <br /> Rev.Aug 2012 <br />