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SAN JOAQUIN VWEY UNIFIED AIR POLLUTION COA. OL DISTRICT <br />Northern Region Office Central Region Office Southern Region Office <br />-11.4230 Kiernan Ave., #130 1990 E. Gettysburg Ave. 2700 M St., #275 <br />Modesto, CA 95356-9322 Fresno, CA 03726-0244 Bakersfield, CA 93301-2373 <br />(209) 557-6400 (559) 230-5950 (661) 326-6900 <br />Station Name: <br />2 3 <br />PTO, <br />Location, <br />City; <br />Phone <br />Location <br />Mailing Address: <br />City: <br />State: <br />Zip: <br />Contact; <br />Title: <br />2. Broken/Missing Fill Cap <br />Inspection Type- Complaint 1 2' Semi -Annual <br />2. Insertion Interlock <br />1 It <br />2"O Follow-up To: --.---- <br />Nozzles Inspected (Model and Dispenser Number): <br />3. Check Valve <br />Phase I System Type, [ ] 2 -Point [ ] Coaxial Phase If System Type: <br />Tank Number 1 <br />-77-7— <br />2 3 <br />4 NoZZ19 Number <br />Product Type <br />Product type <br />Location <br />Nozzle Type <br />1. Broken/Missing Vapor Cap <br />1, Nozzle <br />2. Broken/Missing Fill Cap <br />2. Insertion Interlock <br />3. Vapor Cap Not Seated <br />3. Check Valve <br />4. Fill Cap Not Seated <br />4. Fang? Plato/Sea[ <br />5. Vapor Cap Casket Missing <br />5. Ring/Rivet <br />6. Fill Cap Gasket Missing <br />6. Bellows <br />7. Vapor Adapter Not Tight <br />7. Bellows Clamp/Wire <br />8, Fill Adapter Not Tight <br />8. Swivel(s) <br />9. Dry Break Gasket Deteriorated <br />9. Hold Open Latch <br />10. Gasket Between Adapter <br />and Fill Tube Missing/Not Seated <br />10. Hose <br />11. Hose Configuration <br />11. Coaxial Fill Tube Spring Defective <br />12. Liquid Removal System <br />12, Pressure Vacuum Relief Valve <br />I& GPM <br />13, Other: <br />Incinerator Function System Pressure Signs Posted (X= Qeficiency) <br />Tank Depth <br />Fill Tube Length <br />IDifference (6" or less) <br />4 <br />KEY FOR DEFICIENCIES <br />AD=Adjustmgnt, S=Brokon, F -Flat, FR -Frayed, K=Kinked, 1 -,=tong, <br />LO=Loose, M=Mlssirig, MA=Misaiigned, NC =Not Certified, $=Short, TO=Tom <br />Phase I Report; Check marks indicated component deficiencies <br />Inspection Result(s) '7. - ----- - <br />Phase 11 Report: 7=Repair within 7 days, T=Tagged out of order until repaired <br />U=Taggable violation corrected during inspection <br />s: <br />Comment <br />Inspector: E Date- Received By - <br />When repairs are complete call; <br />Warning: Item(s) checked above in the Phase I portion of the inspection form and Item(s) coded with a,,r, or "U" In the Phase 11 <br />inspection form results category Is/are in violation of Son 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 />ZO 39Vd NOXX3 3NV_1 cJ3WWVH 0968T5660Z T T : 0 0 aV,_W4Z4Z:0 <br />