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Self Inspection Chad;ist; &slance E f>haso N Month: &Ae ID <br /> (including Hirt VCS- 100 systems) and Year: � <br /> SiteName• G l <br /> Two Point Phase IVapor Recovery 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(v)in each box if no problem is found. Mark with an W any box if a problem is found. Record any problems in your repair tog, Keep these <br /> records 1n 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 5 0 11 12 3 i4 15 6 7.18 t9 0' 1 5 6 7 8 0 1 <br /> Tanks area Phase I Vapor Recovery) <br /> �. PV valve--Present. No debit's. Check for shadows. <br /> . <br /> Spill container—Clean and d <br /> S if[cohtainer drain va]ve--Closed not dam ed. l <br /> . <br /> Fill ads er—Ti ht on riser swh e/sro er! . / �. <br /> 5. Fll ads ter ca TI ht,gasket resent, no darns e. l Ei l e= <br /> Fill tube—Present, OPW ack screw assembl tI hf <br /> Wapor adapter—Tight on riser,poppet present, - I JT <br /> all ned/not dam " ed swivels` ro erl . <br /> . Va or c Tr ht asket present. / lAzI <br /> Dispenser Area Phase If Mr Recovery) <br /> 9. Air District decal--Present w/correct toll-fres number <br /> 10. Hose-EVR-certifled,no kinks/slltsltears, LRD <br /> Installed correct( <br /> 11. Nozzle=-EVR-certified,has all clamps,no leaks, <br /> out naf loose ins ect VST nozzle Ball if a licable j /1 l <br /> 12. Latch rtn --Present,!n ood re air J V1 <br /> 13. Bellows and.faceglate—Presentr ingood re a!r <br /> 14. ,Hold open latcch--Present,In good repair(except for <br /> VST nozzle without Secondary Release Me anlsrn <br /> 15. '.irtsertion interlock mechanism---o erates ro ed �.J <br /> 16. Breakawa --Present EVR-cert/fied,no leaks l r- <br /> 17. Drain u or hoses of excess gasoline <br /> 18. Retractor:O' cafesro er! ,in and repair l <br /> Quarterly Inspection: If Installed,Check Healy Clean Air Separator tank for proper ball valve'position. Date inspected: <br /> Ball valve A:a en/elosetl Rall valve B:open/closed Bail valve C:operr/ciosetl Bal!valve Q:open/closed <br /> pits aot®r°s Initials: <br /> Rev.Aug 2012 <br />