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1 ion n }� <br /> urs �rftl c rc�tt� Chi caiz,/,'il[IhcDMt o i Eva R �f aae lll7 Month : � <br /> Year : <br /> (Irrd uding ffla M9400 syr Noose) sand <br /> s;ie Name: <br /> Two Pognt Phase 0 V tfor( F ono vert' Address : <br /> Inspection frequericy: 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 repalr lord . 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 2 4 5 6 7 B 9 1011 12 13 14 15 16 17 118 19 20 21 22 23 24 25 26 zr a8 29 0 31 <br /> Tanks area Phase I Vapor Recover <br /> 1 . PV valve– Present No debris, Check for shadows, l <br /> 2, Spill container— Clean and diry r <br /> 3, Spill container drain valve—Closed not dama. ed <br /> Ti <br /> 4. Fill ada ter— ht on riser, swivels roere , <br /> 5 . FIII adapter ca — T, ht, gasket present, no damage, C — <br /> 6 . Fill tube—Present, DPW jackscrew assembly ti ht _ <br /> 7. Vapor adapter— Tight on reser, poppet present, — — — — <br /> alklnedlnot damaged, swivels propiLly. <br /> 8 . Vapor ca Ti ht, gasket present. / — <br /> Dispenser Area Phase Il vapor Recover <br /> 9 . Air District decal—Present w/correct toll-free number F — � 4or <br /> l l l r <br /> 10. Hose—EVR-certified, no kinks/slits/tears, LRD — <br /> Installed correctlyl l <br /> 11 . Nozzle—EVR-certified, has all clamps, no leaks, —spout not loose (inspect VST nozzle daily, if applicable) l / / <br /> 12. Latch rin - Present, ingood repair <br /> 13 . Bellows and face late—Present; in good re air — <br /> 14 . Hold open latch—Present, In good repair,(ercept for <br /> VST nozzle without Secondary Release Mechanism <br /> 15 . Insertion interlock mechanism--operates proper] J <br /> 16. Breakaway—Present, EVR-certified, no leaks c l l <br /> 17. drain vapor hoses of excess gasoline <br /> 18 . Retractor—Operates properly, in good repair — — <br /> Quarterly Inspection : If installed, Check }-leafy Clean Air Separator tank for proper ball valve position . Date Inspected : <br /> Ball valve A : open/closed Ball valve B : open/closed Ball valve Co open/closed Ball valve D : open/closed <br /> Rev. Aug 2012 <br />