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Scoff InSpectlion Chec ffis a Bay EYR Phase ff Monte ? <br /> (including 94W VC3m 100 systaons) and Year: <br /> Site Name : <br /> Two PoidI 1] t Flues I Valcor Recover 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 fog. 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 /> Dav of the Month <br /> 1 2 5 6 7 11 19 110 111 12 13 i4 15 i6 17 18 19 20 21 22 23 24 25 26 27 128 pq P07M <br /> Tanks area Phase I Vapor Recover <br /> . PV valve— Present: No debris. Check for shadows. / <br /> 2. Spill container—Clean and dr / <br /> 3. Spill container drain valve—Closed not dama ed. <br /> ro <br /> 4. Fill adapter— Tiht on riser, swivels erl . <br /> 5. FIII adapter ca Tight, asket present, no dama e. <br /> 6. Fill tube—Present, DPW ack screw assqmbl <br /> y tight <br /> 7, Vapor adapter— Tight on riser, poppet present, — <br /> ali ned/not damaged, swivelsro erl , " <br /> [Be Vapor ca Ti ht, gasket present, <br /> Dispenser Area Phase 11 vapor Recover <br /> 9. Air District decal—Present w/correct toll-free number l �/ . <br /> 10 . Hose—EVR-certified, no kinks/slits/tears, LRD <br /> installed correctly / ✓ V / / Id / <br /> 11 . Nozzle—EVR-certified, has all clamps, no leaks, <br /> spout not loose (inspect VST nozzle daily, if iapplicable v / / <br /> 12. Latch ring—Present, ingood repair / i ; � , / e i <br /> 13 . Bellows and faceplate—Present, in good re air i / <br /> 14. Hold open latch—Present, In good repair (except for ✓ / / / / / ! / , / / <br /> VST nozzle without Seconda Release Mechanism <br /> 15. Insertion interlock mechanism- p erates properiv l / X <br /> 16. Breakaway--Present, EVR-certified, no leaks <br /> 17. Drain vapor hoses of excess gasollne <br /> 18. Retractor—G erates pyoperly, in good <br /> Quarterly Inspection : If installed, Check Healy Clean Air Separator tank for proper ball valve position . Date Inspected : <br /> Ball valve A : openiclosed Ball valve Be open/closed Ball valve C : open/closed Ball valve D : open/closed <br /> Rev. Aug 2012 <br />