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R �. ,, r o �; Month : <br /> So»r dni s I� er, §ai � Chi c-�c, Hoot,� LSak �� ESR 'D � 1 C dd Year : <br /> (Ir/tJdUIding HN �fCv(9R)= W0) 0 s sta4ns) aen d Site Name : <br /> TWO P09n Pease d Wnpor( 1IT On y Address . <br /> Inspection frequency: l=ive (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 "X" any box If a problem is found. Record any problems In you'r repair lop . 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- 12 4 5 16 11 18 9 PT 12 113 ji4 115 116 1117 16 119 101F 22 23 24 25 26 1 127 28 29 PO 1 <br /> Tanks area Phase I Vapor Recover <br /> . PV valve— Present No debris. Check for shadows. r- `' ! -� <br /> 2. Spill container— C/ean and dr r' s� Z / . " / X . f l <br /> 3. Spill container drain valve—Closed not dama. ed. " / <br /> 4. Fill adapter— Tight on riser, swivels ro erl , / �� � % _ <br /> 5. FIII adapter cap— Tight,ht, asket resent, no damage. <br /> 6 . Fill tube—Present, DPW jackscrew assemblytight _ <br /> 7, Vapor adapter— Tight on riser, poppet present, <br /> all ned/not dammed, swivels ro erl . 07 P <br /> _ <br /> 8 . Vapor ca Ti ht, gasket resent. f' <br /> Dispenser Area Phase II vapor Recover <br /> 9. Air District decal—Present w/correct toll-free number / l <br /> 10 . Hose—EVR-certified, no kinkslslits/tears, LRD `` „_ f <br /> Installed correcfl <br /> 11 . Nozzl e—EVR-certified, has all clamps, no leaks, <br /> s out not loose inspect VST nozzle daily, if a licable / F �` <br /> 12, Latch rin - Present, in good repair l <br /> 13 . Bellows and face fate—Present, in good re air / f <br /> 14. Hold open latch—Present, In good repair (except for <br /> VST nozzle without Secondary.Release Mechanism44 % <br /> 15, Insertion interlock mechanlsm--o erates ro erly <br /> 16 . Breakaway--Present, EVR-cerf/fied, no leaks <br /> 17. Drain vapor hoses of excess gasoline _ <br /> 18. Retractor—O erates roerl , in ood re air <br /> Quarterly Inspection : If installed, Check Healy Clean Air Separator tank for proper ball valve position . Date Inspected : <br /> Ball valve A : open/closed I Ball valve B : open/closed Bali valve C : open/closed Ball valve D : open/closed <br /> �__. _. .� ���p���c��''� d�►di#ia�� ° �- �--��--�—�I�_1_T__�__I _ _.Cl—�I__1Z�.���1Y1 <br /> Rev. Aug 2012 <br />