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�r7 9hapact oo n Chi ac//,tDoti BE ak Onc( ce EVR Phase Y# Month : <br /> Year: l <br /> (in c9uding 9171d VCSSm 0) 0 systems) and Site Name : <br /> Two Po garl 17t Ph(28a lI valao0 r RccaView,-y Address : <br /> Inspection frequency: Five (5) days per ween, 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 lord, Keep these <br /> records In your Operations and Maintenance manual for five (5) years, see the reverse side of this form for more Inforrnation. <br /> Dav of the Month <br /> 1 2 3 4 5 6 7 8 9 10 11 112113 JO14115 16 17 f 8 19 2021 22 23 24 25 26 27 26 9 0 31 <br /> Tanks area Phase I Vapor Recover <br /> 1 . PV valve—Present: No debris. Check for shadows, l lAA elefIlOOVIA111 pp Al <br /> 2, Spill container— Clean and di ! l / i l l l l <br /> 3. Spill container drain valve—Closed not dama ecl <br /> 4. Fill ada ter— Ti ht on riser, swivels propqrlKs eA . <br /> 5. Fill adapter ca — Ti ht, asket resent, no dama e. Z e <br /> r l <br /> S . Fill tube—Present, DPW jackscrew assembly ti ht <br /> 7, Vapor adapter-- Tight on riser, poppet present, - - <br /> ali ned/not damaged, swivelsro erl . <br /> 8 . Vapor caTightcjasket present,Dispenser Area Phase 11 vapor Recover <br /> 9. Air District decal—Present w/correct toll-free number Ll <br /> 10 . Klose—EVR-cejtlfied, no kinics/slits/tears, LRD — <br /> ft <br /> installed correcfl <br /> 11 . Nozzle--EVR-certified, has all clamps, no leaks, <br /> 00 <br /> spout not loose (inspect VST nozzle daily, if applicable) <br /> 12 , Latch ring--Present, ingood repair <br /> 13 . Bellows and faceplate--Present, in good re air <br /> 14 . Hold open l atch—Present, in good repair (except for <br /> VST nozzle without Secondai Release Mechanism <br /> 15 . Insertion interlock mechanism—operates properly <br /> 16 . Breakaway—Present, EVR-certified, no leaks <br /> 17. Drain vapor hoses of excess gasoline _ <br /> 18 . Retractor—O erates properly, in good repair Irl <br /> Quarterly Inspection : If installed, Check Healy Clean Air Separator tank for proper ball valve position . Date Inspected : <br /> Ball valve A : open/closed Ball valve B : open/closed Bali valve C : open/closed gall valve D : open/closed <br /> Rev. Aug 2012 <br />