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SAN JOAQUIN V EY UNIFIED AIR POLLUTION CONt OL DISTRICT <br />t.•<;j Northern Region Office [ j Central Region Office [ ] Southern Region Office <br />4230 Kiernan Ave., #130 1990 E. Gettysburg Ave, 2700 M St., #275 <br />Modesto, CA 95356-9322 Fresno, CA 93726-0244 Bakersfield, CA 93301-2373 <br />(209) 557-6400 (559) 230-5950 (661) 326-6900 <br />Station Name: PTO: I ' 1- <br />Location: _ City,-- Phone #: <br />Mailing Address: City: State: zip: <br />Contact: Title: <br />Inspection Type: [ ] Complaint [ j 1 st [ ] 21 Semi -Annual J 111 [) 2ntl Follow-up To: <br />Nozzles Inspected (Model and Dispenser Number): ' <br />Phase I System Type: [ ] 2 -Point [ ] Coaxial Phase II System Type: - <br />Tank Number 1 2 3 4 Nozzle Number <br />Product Type Product Type r h <br />Location Nozzle Type i t( <br />1. Broken/Missing Vapor Cap 1. Nozzle <br />2. Broken/Missing Fill Cap 2. Insertion Interlock <br />3. Vapor Cap Not Seated 3. Check Valve <br />4. Fill Cap Not Seated 4. Face,Plate/Seal <br />5. Vapor Cap Gasket Missing 5. Ring/Rivet <br />6. Fill Cap Gasket Missing 6. Bellows <br />7. Vapor Adapter Not Tight 7. Bellows Clamp/Wire <br />8, Fill Adapter Not Tight 8. Swivel(s) <br />9, Dry Break Gasket Deteriorated 9. Hold Open Latch <br />10. Gasket Between Adapter 10. Hose <br />and Fill Tube Missing/Not Seated 11. Hose Configuration <br />11. Coaxial Fill Tube Spring Defective 12. Liquid Removal System <br />12. Pressure Vacuum Relief Valve 13. GPM <br />13. Other: [ ] Incinerator Function [ ] System Pressure [ ] Signs Posted (X= Deficiency) <br />Tank Depth KEY FOR DEFICIENCIES <br />Fill Tube Length AO=Adjustment, B=Broken, F=Flat, FR=Frayed, K�Kinked, L=Long, <br />E22222 2" or less) LO -Loose, M=Missing, MA=Misaligned, NC=Not rartified, S=Short, TO=Torn <br />vnase i rteport: VnecK marcs inaicaieo component aencienues 1nspeusiur1 IWbUItkaj <br />Phase 11 Report: 7=Repair within 7 days, T=Tagged out of order until repaired <br />U-Taggable violation corrected during Inspection <br />Comments: <br />Inspector: Date: I - '� Received By: :41 <br />_.. <br />When repairs are complete call: ( <br />Warming: Itern(s) checked above in the Phase I portion of the inspection form and itern(s) coded with a "T" or "U" In the Phase It <br />inspection form results category isfare in violation of San Joaquin Valley Unified Air Pollution Control District rule(s). The <br />California Health & Safety code specifies penalties for each day of violation(s). <br />Note: CA Health & Safety code, Section 41960.2(e) requires that the above listed 7 -day deficiencies be repaired within 7 days. <br />Failure to do so will result in legal action. <br />60 39Vd NOXX3 3NVI 63WWVH 096STS66OZ ZT:00 <br />