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SERVICE STATION CHECKLIST <br />WIC#: 95775 <br />DISPENSER AREA <br />Product <br />Dispenser <br />Manufacturer <br />Number <br />of <br />Nozzles <br />Impact <br />Valves <br />Operational <br />Dispenser <br />Containment <br />Box <br />Containment Sensor: <br />Mechanical, Electronic or None <br />If electronic, write model type. <br />Containment <br />Sensor <br />Operational <br />B.S.: Balance System <br />H. S.: Healy System <br />V.A.: Vacuum Assist <br />Regular <br />GILBARCO <br />8 <br />Yes <br />No <br />N Model: NA <br />Interior <br />B.S. <br />Plus <br />GILBARCO <br />3 <br />No <br />N Model: NA <br />B.S. <br />Premium <br />GILBARCO <br />6 <br />No <br />N Model: NA <br />B.S. <br />Diesel <br />Model: <br />M-85 <br />Model: <br />Comments: <br />General Information: <br />GENERAL INFORMATION <br />Are Pressure Relief Valves <br />Installed On Vent Line Stacks <br />Emergency <br />ESO <br />Qty <br />Shutoff (ESO) <br />Operational <br />No <br />Present <br />1 <br />Exterior <br />Yes <br />Yes <br />1 <br />Interior <br />Yes <br />Yes <br />General Information: <br />GENERAL INFORMATION <br />Are Pressure Relief Valves <br />Installed On Vent Line Stacks <br />Regular <br />No <br />Plus <br />No <br />Premium <br />No <br />Diesel <br />M-85 <br />Rev: 1/31/95 Page 3 of 3 <br />