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G'lll i�dsJec�llOOlt17 Cllf7eci of oBaleEVR Mae ill Month : <br /> (iand <br /> Hirt VC�8mV 00 s . stains d NMI <br /> Year: o � <br /> Site Nam : <br /> TWO ®dl�t] " l�l�'11�eC �ct��©f� eCDv�'f�'�y 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 repa6• log. Keep these <br /> records In your Operations and Maintenance manual for five (5) years. See the reverse side of this forth for more information. <br /> Da of the Month <br /> 1 12 P r 5 6 17 18 19 10 11 12 13 14 115 116 ItI7118119120121 122123 24 Ina InC 27 c8 9 0 1 <br /> Tanks area Phase I Vapor Recover 00 it I it, <br /> 1 . PV valve--Present. No debris. Check for shadows. ✓ J VV ,/ � �j v 1 , <br /> 2. Spill container— Clean and dr v V ✓ �, v ,� v ✓ <br /> 3. Spill container drain valve—Closed not damaged. ✓ ✓ ✓ 7 v' � ,,o/ ` <br /> 4. Fill adapter— Tight on riser, swivels properly, ✓ ✓ . v V <br /> 5. FIII adapter ca T1 ht, gasket resent, no dama e. ,/ ✓ ✓ o4l ✓ v V <br /> Be Fill tube—Present, OPINack screw assembly ti ht <br /> 7. Vapor adapter— Tight on riser, poppet present, <br /> all ned/not damaged, swivels pLoperly, " <br /> 8. Vapor ca Ti ht, gasketpresent. I Nil V � ,/ ,/ ✓ • ✓ , . ` <br /> Dispenser Area Phase II vapor Recover <br /> 9 . Air District decal—Present w/correct toll-free number V V Vv A o0v �V/ V ✓ A VfV1 VI! , <br /> 10. Mose—EVR-certified, no kinlrs/slits/tears, LRD <br /> installed corracfl `� dv/ ' V <br /> 11 . Nozzle—EVR-certified, has all clamps, no leaks, i/ ✓ ✓ J 4 Ii/ V// V/ J ` <br /> spout not loose ins ect VST nozzle dais , if a licabletell <br /> 12. Latch ring—Present, in qood re air V ;/ ,j <br /> 13. Bellows and faceplate—Present, ingood re air / • � v , J v <br /> 14. Hold open latch—Present, In good repair (except for V <br /> VST nozzle without Seconds Release Mechanism d, vile I <br /> 15. Insertion interlock mechanism--operates properIv / ,/ v V V i ./ . V . ' <br /> 16. Breakawa --Present, EVR-certified, no leaks ✓ J ✓ 1 %, Vo <br /> 17. Drain vapor hoses of excess gasollne <br /> 18. Retractor-0erates properly, in ood repair ✓ <br /> Quarterly Inspection : /f installed, Check Healy Clean Air Separator tank for proper ball valve position . Date Inspected : <br /> Ball valve A : open/closed Ball valve Be o enclosed Ball valve C : open/closed Ball valve D : open/closed <br /> 4� cec ®re's Paaatia9slip I <br /> . <br /> Rev. Aug 2012 <br />