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Site Number Date �J t <br /> tl NOZOM i, 2w r to xXf J y �, 2 Hose'Retlactors r✓ <br /> (t rz•�•�;� ' -A <br /> _-,r-„16odalNumbar <br /> C L=Callow <br /> Dispenser No.&Fuel Grade EW=Em o Wheaton CA=Cauow <br /> (if applicable) E1=EZ Flo EW=EJmoo Wheaton Are they installed/mounted <br /> for a single hose list HA=Harco Write Model Number in ng propel <br /> ( isp gas space Write Model Number m spew <br /> EBW 8 functioning <br /> dsp#only HL=Healy �vded HE=Healy provided Please write it m <br /> 1 reg utao-,2 midgrade,3.4, HK=Husky HU=Husky P Yes or No <br /> 5 diesel,etc) OPW OPW NA=None <br /> VST=Vapor Sys L VST=Vapor Syst <br /> Ci, U A NA <br /> S tJ p w (.QLO-- k 12 C, 1 J,A <br /> J 5-T izvZ S a NA <br /> OY w A NA <br /> S vY-T vt N� o w trip Ci.�7 �JA �A <br /> V S 1vtL O w }J A QA <br /> CM A <br /> .-MOO vs 3 �j lJ A <br /> J jL <br /> I _. <br /> NI <br /> F-MA 111104tt✓tt Comments on any damaged/defadlve equipment <br /> All hanging hardware in <br /> good condition? <br /> N no,Provide comments <br /> to the right <br /> Yes or Na <br /> issued 12127/2017 Page 7 of 10 <br />