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i <br /> SHEAR VALVE OPERATION INSPECTION <br /> o <br /> Facility Name: Owner <br /> �o <br /> Address: Address o <br /> lu <br /> City,State,Zip Code: City,State,Zip Code: <br /> Facility I.D.#: Phone#: o <br /> Testing Company: Phone#: C <br /> This data sheet is for inspecting shear valves located inside dispensers.See PEI/RP1200 Section 10 for the inspection procedure. <br /> Product Grade <br /> CL <br /> Dispenser ID# <br /> d <br /> Shear ValveType(Product/Vapor) o <br /> 1.Is the shear valve rigidly <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? o <br /> 2.Is the shear section posi- <br /> tioned between yz 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? 'r <br /> 0 <br /> m <br /> ❑Yes ❑No ❑Yes []No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes El-No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> 3.Is the lever arm free to move? ❑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 CL <br /> thepoppet valve? 11NA 11NA ElNA ❑NA ❑NA ❑NA 11NA 1 11NA I ElNA `" <br /> 0 <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 ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA_ � <br /> n <br /> 0 <br /> A"No"to Lines 1-4 or a"Yes"for Line 5 indicates a test failure. d <br /> 5' <br /> Test Results 0-Pass ❑Pass ❑Pass 0 Pass 0 Pass ❑Pass ❑Pass <br /> 11 Pass 171 Pas <br /> ❑Fail Fail 17 Fail ❑Fail ❑Fail ❑Fail ❑Fail ❑Fair ❑Fail rM <br /> Comments: <br /> o <br /> Tester's Name(print) Tester's Signature <br /> I <br />