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• i 1 <br /> So(lt� #nsp �r���or� Cclllrric o0 �0 � � U�r� c r> �� IPIn)� TAddress , <br /> I i n Y <br /> �, �� r11 Zc-`l <br /> (�Ini G�� tCl1dQ1lig Hir t VC 3m 1 ©© systems) �11J9cz�9 <br /> TWO �Pol�r7i Phase 4 Vapory �ecover;y � <br /> MINE III so 0 <br /> Inspection frecluency: 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 you'r 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 Information. <br /> Dav of the Month <br /> 1 2 r 4 11 6 7 -1B 9 0 11 12 13 14 15 16 17 18 119120 191 199 23 24 25 26 27 28 29 D 1 <br /> Tanks area Phase I Vapor Recover <br /> 1 . PV valve— Present. No debris, Checlt for shadows. / / i i x ; J <br /> 2, S III container— Clean and dr v <br /> 8. S til container drain valve—C/osed not dams ec1. <br /> 4. Fill ada ter— Ti ht on riser, swivels ro erl , f / <br /> 5. Fill adter ca Ti ht, gasket resent, no dama e. / j / <br /> 6. Fill tube—Present, OPW ack screw assembl ti ht _ <br /> 7. Vapor adapter— Tight on riserIIIiiIIim <br /> , poppet present, <br /> alt ned/not dama ed swivels properl . <br /> B . Vapor ca Ti ht, qasicet present, <br /> Dispenser Area Phase II vapor Recover <br /> 9 . Air District decal—Present w/correct toll-free number <br /> 10 . Hose—EMcertlfied, no kinks/slits/tears, LRD — – ✓ , <br /> installed correct! ` / / / i / / / f / / / V <br /> 11 . Nozzle—EMcertifled, has all clamps, no leaks, — <br /> Iwo ut not loose (inspect VST nozzle dail , if a lic We / / / / / ,/ / <br /> 12. Latch rin •---Present, In good repair XV <br /> 13. Bellows and faceplate—Present, in good repair / / i / , / ✓ ✓ <br /> 14. Hold open I atch—Present, In good repair (except for 1 <br /> VST nozzle without Seconda Release Mechanism / <br /> 15, Insertion interlock mechanisrn � p erates properly <br /> / r T — <br /> 16. Breakawa --Present, EVR-cerflfied, no leaks <br /> 17. Drain vapor hoses of excess gasoline <br /> 18. Retractor—Operates properly, Ingood repair <br /> Quarterly Inspection : If installed, Check Healy Clean Air Separator tank for proper ball valve position. Date Inspected: <br /> Ball valve A : open/clased Ball valve B : open/closed . Ball valve C : ohenlclosed Ball valve D . open/closed <br /> C_E-I-�=�1_-I-J� <br /> Rev. Aug 2012 <br />