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Work Order: 2271161 <br />(H SO) c& (ESV) Testing Form - Vcnion I- 1011.3 ,12009 <br />Emergency Shut Off (ESO) <br />Dispenser Emergency Shutoff Valve (ESV) <br />ANNUAL TEST RECORD LOCATIONS AND TEST DATA <br />Testing TAjN-KNOLOGY <br />Company:_ <br />Location Name: Ste. <br />Address: I I 7 ZS N <br />Date: <br />Store <br />City: I Tv�Cy <br />-------- <br />/01 <br />State ID #: <br />State_ <br />Emergency Shut Off (ESLD) Testing Results <br />,On t tA. in accordance with "ESO Vendor Letter (3-21-05).doc", from Retail Compliance <br />Department, as a part of annual compliance testing, this representative tested the Emergency Smut Off <br />(ESU) switches indicated on this sketch. Findin sg listed below: <br />Emergency Shut Off (ESO)If No, Provide l <br />Operational? 1-0 <br />IS. <br />S Maintenance Log # Date Called <br />Dispenser Emergency Shutoff Valve (ESV) Testin Results <br />On 12 7z de� in accordance with NFPA 30A this representative tested the automatic -closing feature <br />of the bispenser Emergency Shutoff VALVE(S) (ESV) located in the supply lines at the base of each <br />individual island type dispenser indicated on the diagram below. Each device (#) ._...._Z d in all, <br />would automatically close. Findir.._a-, listed below: <br />Disp. Emergency Shut Off 1f No, Provide <br />Valve (ESV) Operational? Maintenance Log # :EDat.c Called <br />j Site Man Of Location and Placemcat of Devices Tested: <br />1 <br />Signature Of Representative: <br />Tanknology Inc. 11000 N. MoPac Expressway, Suite 500, Austin, Texas 78759 <br />