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i r 1 OPERATIONSHEAR VALVE 0 Facility Name: Owner Address: Address Q City, State, Zip Code: City, State, Zip Code. Facility I . D. #: Phone #: o I Testing Company: Phone #: fD� This data sheet is for inspecting shear valves located inside dispensers. See PEVRP1200 Section 10for the inspection procedure. d Product Grade a Dispenser ID# �' II Shear ValveType ( Product/Vapor) 1. Is the shear valve rigidly anchored to the dispenser box ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No frame or dispenser island? o 2. Is the shear section posi- tioned between 1/2 inch above or below the top surface of the p YLON ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes [] No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No EllYes ❑ No ❑ Yes ❑ No � dispenser island? 'r Q 3 . Is the lever arm free to move? ❑ Yes CD ❑ No ❑ Yes 0 N ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑' No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No _ ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA 4. Does the lever arm snap shut ❑ Yes [] No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes [] No ❑ Yes ❑ No [] Yes ❑ No ❑ .Yes ❑ No ❑ Yes [] No o- the poppet valve? ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA 0 5. Can any product be dispensed ¢ ❑ Yes ❑ No ❑ Yes ❑ No ❑ Yes [] No ❑ Yes ❑ No ❑ Yes' ❑ No ❑ Yes ❑ No ❑ Yes [] No ❑ Yes ❑ No ❑ Yes ONo d j when the product shear valve is ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA ❑ NA., Ri closed? 0 A " No" to Lines 1-4 or a "Yes" for Line 5 indicates a .test failure. Test Results ❑ •Pass C7 Pass `❑ Pass 0 Pass ❑ Pass I7 Pass ❑ Pass ❑ Pass ❑Pass ❑ Fail C] Fail b Feil ❑ Fail ❑ Fail ❑ Fail ❑ Fall ❑ Fair ❑Fail m .n Comments: m � I h h 1 C I Z Tester's Name (print) Tester's Signature I