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SON kapection CheaoO;� hot Balance ce EVR T n Tae /N Month : U; <br /> (Orrvduding .Hga VC Sm il00 systaons) and ISite Name : � t <br /> Two Point Phase 11 Valoor� Recovery 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 top , 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 4 5 6 7 8 9 10 11 112 113 114 115 16 17 118 19 1 <br /> 20 121122 23 24 25 26 27 26 29 0 1 <br /> Tanks area Phase I Vapor Recover <br /> . PV valve--Present No debris. Check for shadows. / / v <br /> 2, Spill container— Clean and di ✓ Ole <br /> 8Mz <br /> . Spill container drain valve—Closed not dama ed. ' , i / / <br /> 4. Fill ada ter— Ti ht on riser, swivelsproperly, / i <br /> 5. Fill adapter ca Ti ht, gasket resent, no damage, ✓ _ � <br /> 6. Fill tube—Present, OPW jack screw assemblyfight _ <br /> 7. Vapor adapter— Tight on riser, poppet present, <br /> alt ned/not damaged, swivels roerl . a" <br /> 8 . Vapor ca Ti ht, asket resent. / / / ,/ ✓ / <br /> Dispenser Area Phase 11 vapor Recovery) <br /> 9 . Air District decal—Present w/correct toll-free number or / _ ✓ <br /> 10 . Hose—EVR-certified, no kinks/slits/tears, LRD J / r / f � � ) i J I ✓ J / <br /> installed correctly ✓ J j/ <br /> 11 . Nozzle—EVR-certified, loos all clamps, no leaks, , ✓ f f / J J ✓ J <br /> spout not loose (inspect VST nozzle dais , if a licable ✓ <br /> 12. Latch rin - Present, in good repair J > ✓ <br /> 13. Bellows and faceplate—Present, ingood re air , J _ <br /> 14. Hold open latch—Present, In good repair (except forJ / / ✓ �� J J / f J VY <br /> VST nozzle without Secondary Release Mechanism <br /> 15. Insertion interlock mechanism--operates properly \oo( 7L7/ / r <br /> 16. Breakawa —Present, EVR-certified, no leaks / i <br /> 17. Drain vapor hoses of excess gasoline _ <br /> 18, Retractor—Operates properly, in good re aIr / ✓ 77 4 <br /> Quarterly Inspection : If installed, Check Healy Clean Air Separator tank for proper ball valve position . Date Inspected : <br /> Ball valve A : open/closed Rall valve B: open/closed . Ball valve C : open/closed Ball valve D : oven/closed <br /> ll�ubi�4e —Z - ��1�-�_ <br /> Rev. Aug 2012 <br />