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Seff kaper�glon C hie kite o Balance EVR loll swe 1111 Month : <br /> Year: d <br /> (irncludghg goat VC S= 00 systa ns) and site Name : <br /> TWO Pp1111 iiJtl"' Pham i Wepor ReCr- 0 veTyl 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 log , 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 13 114 16 116 117 18 119 20 121122 23 24 25 26 27 26 29 0 1 <br /> Tanks area Phase I Vapor Recover <br /> 1 . PV valve—Present: No debris. Check for shadows. i <br /> 2. S ill container— Clean and dr l J / <br /> 3. Spill container drain valve—Closed not damaged. o� / i / l <br /> 4a filil adapter— Tkyht on riser, swivels pro erl , i j , / <br /> 5. Fill adapter cap— T17ht, gasket present, no damag <br /> e, / / j / / i / / / / / <br /> 6. Fill tube—Present, OPW lack screw assemb! ti <br /> 7. Vapor adapter— Tight on riser, poppet present, <br /> aligned/not damaged, swivels ro erl . <br /> B . Vapor ca Ti ht, gasket resent, <br /> Dispenser Area Phase 11 vapor Recover <br /> 9 . Air District decal—Present w/correct toll-free number _ i / / / <br /> 10 . Hose— EVR-certified, no !finks/slits/tears, LRD <br /> Installed correct/ <br /> 11 . Nozzle—EVR-certified, has all clamps, no leaks, / <br /> spout not loose einspect VST nozzle daily, if applicable) / ( J / / / / / / A / <br /> 12. Latch rim - Present, ingood repair l / / / i i l / / i <br /> 13 . Bellows and face l ate—Present, in good re air / ✓ / l / / / , / / / / / / <br /> 14. Hold open latch—Present, In good repair (except for <br /> VST nozzle without Seconda Release Mechanism / <br /> 15. Insertion interlock mechanism---o erates ro erly / ' / ro / / ij <br /> 16 . Breakawa •--Present, EVR-cert/fied, no leaks i / / , / / ✓ / ✓ <br /> 17. Drain vapor hoses of excess gasoline <br /> 18. Retractor—Operatesproperly, in good repair / / / PW/ / / j <br /> Quarterly Inspection : If installed, Check Healy Clean Air Separator tank for proper ball valve position. Date Inspected: <br /> ( Ball valve A : open/closed Sall valve B : open/closed" `Ball valve <br /> —C : open/ctosed Ball valve D : open/closed <br /> L _ _ llrti @poctp#''s g ritial <br /> Rev. Aug 2012 <br />