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� A UST System Impact Valve Testing <br /> MROOLES"E <br /> Location Name : Costco # 1091 Lodi Date : 05/21 / 19 <br /> Address : 322 E . Harney Lane City : Lodi State : Ca <br /> Dispenser Product Impact Valve Impact Valve <br /> Number Grade Secure? Locks ? Test Result Comments <br /> 1 -2 87 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 1-2 91 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 3 -4 87 ® Yes ❑ No ® Yes [:] No ® Pass ❑ Fail <br /> 3 -4 91 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 5- 6 87 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 5 - 6 91 ® Yes [:] No ® Yes [:] No ® Pass ❑ Fail <br /> 7-8 87 ® Yes [:] No ® Yes ❑ No ® Pass ❑ Fail <br /> 7-8 91 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 9- 10 87 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 9- 10 91 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 11 - 12 87 ® Yes [:] No ® Yes ❑ No ® Pass ❑ Fail <br /> 11- 12 91 ® Yes ❑ No ® Yes ❑ No ® Pass ❑ Fail <br /> 13 - 14 87 ® Yes [:] No ® Yes ❑ No ® Pass ❑ Fail <br /> 13 - 14 91 ® Yes [:] No ® Yes ❑ No ® Pass ❑ Fail <br /> 15 - 16 87 ® Yes [:] No ® Yes ❑ No ® Pass ❑ Fail <br /> 15 - 16 91 ® Yes [:] No ® Yes ❑ No ® Pass ❑ Fail <br /> Dyes ❑ No ❑ Yes ❑ No ❑ Pass ❑ Fail <br /> Dyes ❑ No Dyes ❑ No ❑ Pass ❑ Fail <br /> Dyes ❑ No ❑ Yes ❑ No ❑ Pass ❑ Fail <br /> Dyes ❑ No Dyes ❑ No ❑ Pass ❑ Fail <br /> ❑ Yes ❑ No Dyes [:] No ❑ Pass ❑ Fail <br /> ❑ Yes ❑ No Dyes [:] No ❑ Pass ❑ Fail <br /> Dyes [:] No ❑ Yes ❑ No ❑ Pass ❑ Fail <br /> Dyes [:] No Dyes ❑ No ❑ Pass ❑ Fail <br /> I <br /> ❑ Yes [:] No ❑ Yes ❑ No ❑ Pass ❑ Fail <br /> ❑ Yes ❑ No ❑ Yes [:] No ❑ Pass ❑ Fail <br /> Dyes ❑ No ❑ Yes ❑ No ❑ Pass ❑ Fail <br /> Dyes ❑ No ❑ Yes ❑ No ❑ Pass ❑ Fail <br /> Dyes ❑ No ❑ Yes ❑ No ❑ Pass ❑ Fail <br /> ❑ Yes ❑ No Dyes ❑ No ❑ Pass ❑ Fail <br /> Revised 11/03/2014 <br />