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i <br /> OPERATIONSHEAR VALVE <br /> Facility Name: Owner 3 <br /> Address: Address <br /> City,State,Zip Code: City,State,Zip Code: ° <br /> Facility I.D.#: Phone#: <br /> 0 I <br /> Testing Company: Phone#: 1' <br /> This data sheet is for inspecting shear valves located inside dispensers.See PEI/RP1200 Section 10 for the inspection procedure. tM' <br /> Product Grade � <br /> CL <br /> Dispenser ID# <br /> d <br /> Shear ValveType(Product/Vapor) <br /> o' <br /> 1.Is the shear valve rigidly o <br /> 1 <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 /> v <br /> frame or dispenser island? o <br /> 2.Is the shear section posi- a <br /> tioned between 1/2 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? <br /> 0 <br /> ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ONo ❑Yes ❑No _ fD <br /> 3.Is the lever arm free to move? o <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 a <br /> the poppet valve? ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA <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 13NA 11NA ❑NA ❑NA ❑NA ❑NA ❑NA_, <br /> 0 <br /> A"No"to Lines 1-4 or a"Yes"for Line 5 indicates a test failure. Fv <br /> Test Results ID Pass 11 Pass ❑Pass ❑Pass El Pass ❑Pass ❑Pass ❑Pass ❑Pass <br /> ❑Fail ❑Fail 13 Fail ❑Fail ❑Fail ❑Fail ❑Fall ❑Fail ❑Fail <br /> Comments: <br /> -o' <br /> UM <br /> �o <br /> � m I <br /> m <br /> o � <br /> U <br /> ® Tester's Name(print) Tester's Signature <br /> I <br />