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i <br /> OPERATIONSHEAR VALVE <br /> 6 <br /> Facility Name: Owner <br /> m <br /> Address: Address a <br /> City,State,Zip Code: city,State,Zip Code: a <br /> Facility I.D.#: Phone#: c <br /> Testing Company: Phone#: <br /> w <br /> This data sheet is for inspecting shear valves located inside dispensers.See PEI/RP12O0 Section 10 for the inspection procedure. <br /> Product Grade j <br /> a <br /> Dispenser ID# f° <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 b• <br /> frame or dispenser island? _ <br /> 0 <br /> 2.Is the shear section posi- <br /> tioned between'/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? <br /> � p <br /> 3.Is the lever arm free to move? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No _ <br /> DNA El NA DNA DNA DNA 0 N DNA DNA ❑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 � <br /> when the product shear valve is ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No v <br /> closed? ❑NA ❑NA ElNA ❑NA ❑NA 11NA ❑NA ❑NA ❑NA. <br /> 0 <br /> A"No"to Lines 1-4 or a "Yes"for Line 5 indicates a test failure. d <br /> Test Results ❑Pass ❑Pass ❑Pass ❑Pass ❑Pass ❑Pass ❑Pass ❑Pass ❑Pass <br /> ❑Fail ❑Fail ❑Fail ❑Fail ❑Fail ❑Fail ❑Fall ❑Fail ❑Fail <br /> Comments: c <br /> m <br /> � d I <br /> C. c <br /> Tester's Name (print) Tester's Signature n <br />