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i SHEAR VALVE OPERATION INSPECTION UOUID SENSOR FUNCTIONALITY TESTING Facility Na :me0wnar FACllity NDmD: Owner: Address: Address: Addmav PLdroaa ( a Chy, Sema, ZIP was: dry, them, ZIP Coda: v a� Chy, Stam, Zip Code: CRY, Sum. LP Code: 3 ( Pacilhy I.D. d: Phone a: Facility I.D. k: Phone Y: `•� Testing Compaty. "one s: Data: $ Thb promdure inWdetermine whether liquid noncom bmmd In the lnmrsftlal spew of usF systems aro able m desidthe prisanm of water and fuel. Son PEI/RP]200 n Testing Campam/, Phone Y: n notes 8.3 for the test procedure. This data shoat to far Inspecting liver valloa tocand Inside dbpemem. Sao PEIVRP1200 Section 10 for Na installation procedure. 2 SOnsar Location Product GrOm a Product Stated '3 ❑ Discriminating ODIncrlmineUng ODisttlmlmtlng ❑ DlsMminadng ❑ Dlmdminating ODiacrimineting ❑ Dlecdminadng 9. DismnserlDM Type of Sander ❑ Nondlacdmk ❑ Non-abcdm4 ❑ Non,clwamcF ❑ NonChsdmp ONoealsttlmF ❑ NcnEimriml, 0No"hwim4 Shoar VaNelype (ProdutVVapor) 3 notingnaUng mting mang noting noting noting Teat Liquid ' ❑mair ❑ water ❑ water, ❑water ❑VAmr ❑ water ❑water J. Is the shear vriW rigidly ❑ produce OProduat Opreduct ❑ Product ❑ Product ❑ product ❑ protect anchored W no dispenser boa r0jYwONo ❑Yea ❑Ne OYm ONO OYov ❑ No ❑Yoe ONO ❑Yee ONo ❑Yee ONO ❑Yea ❑ N¢ ❑Yes ONO $ to the ATG console Geer of any active fmmO or tlbpenser loland? 9 mcurdng warnings or alarms2. Is No shear section goal- mgaNingNole¢k vonvaY/ MNa ❑Vila ❑ No ❑Yea ❑ No ❑Yes ONO ❑Yeo ONO ❑Yea ❑ No ❑Yeo ❑ NO ❑YOv ❑ NOtlgnpd between t4 inch ebew ❑Yes ONO ❑Yes ONO ❑Yes ONO ❑Yea ❑ No Met ❑ No ❑Yes ONO OYm ONO ❑Yes ONO - 2' 1 cannot is In alarm and functlonin& or balmy the top surhm of me Indlmm why, dispenser laws? Ie m tnrelnr clmult Oyes ONO ❑Yee ONO ❑Yes ONO Clam ONO ❑Yeo ONo OYn ONO ❑Yon ❑ NO ❑Yes ONo ❑Yn ❑ N¢ ❑Yea ONo ❑Y ONO ❑Yes ONO ❑Yes Me Mone ❑ NO ❑Yeo ONo ❑Yea ONo _ opomdomUonai7 3. ICNobverarmfiootorn m4 - 3 OMam ❑ NA ❑ NA ❑ NA 0 N ONA ❑ NA ❑ NA Mac censor boon Inspected and in ❑yes 0 N ❑Yeo ❑ NO ❑Yea ONO OYOC ❑ No ❑Yeo ONO ❑Y ONO ❑Yes ONo C 4. Dom the lowror snap ¢hut ❑Yee ONo ❑Yea ONO ❑Yes ON¢ ❑Yes ❑ No OYaa ❑ Na OYm ❑ NO ❑Yes ❑ No OYes ONo ❑Yes ONo ^L gootl operating condition? $ the poppa[velva? ONA 0 N ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑NA ❑ NA When placed In Netmtliquid, tlma ayes ONO ❑Yea ONo ❑Yes ONO ❑Yes ONo ❑Ye> ONO ❑Yes ONO ❑Yoe ONO S S, CaneMproducthedlsmnkd ❑yea ONO ❑Yas ONo ❑Yas 0 N ❑Yes ONO ❑Yes- ONO ❑Yee ONO ❑YOc ❑ No ❑Yes ❑ No ❑Ya¢ ❑ No the sonacrmggcr on alert 'c when no produR ahaarvalvv is I Mon on alar Is Waomd, la Ne Oloaed? ❑ m ONA CIM ONA ❑ NA 13 NA ❑ NA ONA DNA, cenmrprop¢M ldantlfletl an the ATG ❑Yea 0 N ❑Y06 ONO ❑Yea ONO ❑Ya¢ ONO ❑Yea ONO MY= 13 No ayes ONO 0 A "NO' is Ease 44 Or a Yeo" for line 5Indimma a test mine, Woods? Teat Imams ❑ Pres ❑ Pam ❑ Pose ❑ Pons ❑ Pam ❑ Pam Opens ❑ Pam ❑Pons AY 'No' enswem lntlkema No aenacrlelisthe maL ❑ Fail ❑ Fag ❑ Fail ❑ Fail '❑ PoO OFali ❑ Fall ❑ Fell ❑EDIT m Test Rvsuils ❑ Pons ❑ Fell ❑ Paas ❑Foil Dennis Opel[ ❑ Pons ❑fail ❑Pons ❑ PoII ❑ Pons ❑ FOA OPem ❑ Fail Continues: y6. Cammema: y m. as ® Tester's Name (print) Tester's Signature I ® Tester's Name (prim) TmtnYs Signature {P7 gg I N r nR c " . fid' �/ i e � 5' 's � � 3a a p Q � a as _ a � e � � Goaor sa � BsnasAz z � z � 3m °„ 3att m � � � � � aV � � �ax � " € F xgs3o a $ g ^ m E : as b gKa� ; � 3 � ix � m y � ma a3e � g � a"- Sd m o Ba C � gP � � � gm l¢ m ' 3a9q � A riB 2 1 3$ 'o'- a o > o o` 3 0 0 a ❑ ❑ ❑ 'my- r ❑ ❑ m 6 RS a 0 ❑ ❑ ❑ 0 0 ❑ ❑ 3 € o m 'a w - Gg� ❑ ❑ ❑ ; ❑ ❑ ❑ y ❑ ❑ gp ❑ ❑ ❑ ❑ ❑ O ❑ ❑ ❑ n q p ❑ A` 13 13 0 0 IT In CIM ❑ to 13 ❑ ❑ ❑ ❑ os ' a ❑ ix 'x g` d CiC ❑ ❑ 0 ❑ b $ i ❑ ❑ ❑ 0 ❑ ❑ ❑ ❑ ❑ � `� ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 8 o ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ A o o 0 0 0 0 0 ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ m ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ ❑ 6 i' ❑ ; ❑ ❑ ❑ ❑ ❑ Or _ 0 03