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Work Order: 2272103 <br /> (F.SO)&(psV)Testing Form-Version 1-2192010 <br /> IF <br /> Emergency Shut Off (ESO) & <br /> Dispenser Emergency Shutoff Valve (ESV) <br /> ANNUAL TEST RECORD LOCATIONS AND TEST DATA <br /> Testing TANKNOLOGY 2 r 5 /� <br /> Company; Date: <br /> Location Name: WTL & Gr Store# 95T State ID#: <br /> Address: /53 a. /•/±1 r City: Ti^r.�c State: GO <br /> Emergency Shut Off(ESO) Testing Results <br /> On 2-T ID in accordance with"ESO Vendor Letter(3-21-05).doe',from Retail Compliance <br /> Department, as a part of annual compliance testing, this representative tested the Emergency Shut Off <br /> SO switches indicated on this sketch. Findin s listed below: <br /> Emergency Shut Off(ESO) If No,Provide <br /> Operational? (!DIN Maintenance Log# Date Called <br /> Dispenser EmeKgency Shutoff Valve (ESV) Testing Results <br /> On 2.5.10 in accordance with NFPA 30A this representative tested the automatic-closing feature <br /> of the Dispenser Emergency Shutoff VALVE(S)(ESV) located in the supply lines at the base of each <br /> individual island type dispenser indicated on the diagram below. Each device(#) in all, <br /> would autolnaticall close. Findin s listed below: <br /> Disp.Emcigcncy Shut Off If No,Provide <br /> Valve(ESV)Operational? /N Maintenance Log# Date Called <br /> Site Map Of Laeation and Plat m of Devices Tested: <br /> 4J Q� V Lj <br /> Signature Of Representative <br /> Tanknology Inc. 11000N. MoPac Expressway, Suite 500,Austin,Texas 78759 <br />