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i <br /> SHEAR VALVE OPERATION . IC <br /> 0 <br /> Facility Name: Owner 3 <br /> 3 <br /> m <br /> C <br /> Address: Address c <br /> City,State,Zip Code: City,State,Zip Code: 6 <br /> Facility I.D.#: Phone#: o <br /> Testing Company: .Phone#: � <br /> This data sheet is for inspecting shear valves located Inside dispensers.See PEI/RP1200 Section 10 for the inspection procedure. ' I, <br /> Product Grade <br /> CL <br /> Dispenser ID# — <br /> d <br /> Shear ValveType(Product/Vapor) <br /> o' <br /> 1.Is the shear valve rigidly <br /> v I. <br /> anchored to the dispenser box ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No — <br /> frame or dispenser island? _ <br /> 0 <br /> 2.Is the shear section posi- <br /> tioned between i/z inch above ❑Yes ❑No ❑Yes ❑No ❑Yes []No ❑Yes ❑No ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No — <br /> or below the top surface of the <br /> dispenser island? PIT- <br /> v <br /> ❑Yes 11 No ❑Yes []No ❑Yes ❑No []Yes ❑No []Yes ❑No ❑Yes ❑'No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No tD <br /> 3.Is the lever arm free to move? <br /> ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA <br /> d <br /> 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 c <br /> the poppet valve? ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NAtArn <br /> o <br /> 5.Can any product be dispensed ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑Nowhen <br /> d <br /> closed?a product shear valve is p NA ElNA ❑NA ❑NA ElNA 11NA ❑NA 1:1NA ❑NA_, <br /> 0 <br /> A"No"to Lines 1-4 or a"Yes"for Line 5 indicates a test failure. <br /> Test Results ❑Pass ❑Pass ❑Pass ❑Pass ❑Pass Cl Pass ❑Pass ❑Pass ❑Pass CD <br /> ❑Fail ❑Fail ❑Fail ❑Fail ❑Fall ❑Fail ❑Fail ❑Fall ❑Fail rn <br /> Comments: 00 <br /> m <br /> rc r+ <br /> o <br /> Un <br /> T <br /> ID <br /> ® Tester's Name(print) Tester's Signature N <br />