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- f <br /> Site Number Date <br /> Nozzles Breakaways Nozzles <br /> Dispenser# Manufacturer Model Number Manufacturer I Model Number Dispenser# Manufacturer Model Number Manufactuaways rerk Model Number <br /> Dispenser No,8 Fuel CA=Caticw CA=Cat�ow <br /> Grade(if applicable) EW=Emco Wheaton CA=Callow Dispenser No.8 Fuel <br /> EW=Emco Wheaton <br /> (for a single hese as HA=Harco EW=Emco wt Grade(if applicable) CA=Cagow <br /> 9 y Write Model Number HE=Healy Write Model Number (for a single hose gas HA=Harco EW=Emco Wt <br /> list disp.#only HK=Husk ins ace Write Model Number <br /> p provided in HK=Husk Write Model Number <br /> 1 regular,2 midgrade HL Healy HU=Husky Pace provided list disp.#only y in space provided HE=Healy <br /> OPW 1 regular,2 mitl HL=Healy HU=Husky In space Provided <br /> 3,4,5 diesel,etc) OPW 9 grade <br /> VST=Vapor Syst 3,4,5 diesel,etc) DPW DPW <br /> VST=Vapor Syst. <br /> F <br /> I <br /> 4s l� s-•-� <br /> ,if <br /> E ' <br /> Tank Field <br /> Observation Price/ID Sign Canopy *Elasomenl Billboard Other <br /> Wells <br /> Quantity of Does the site has an Is the canopy: entObservation Wells ID sign over 30 feet S=Arched Solar Panel Attached or Freer Is there a Billboard on the property? Does the site sell E-65,B6 to 820 or <br /> high F=Flat Non-Solar Deck Standing? ys? have an Electric Car Charging Stat onsWrite in number NA=No Canopy Yes or No <br /> UNK=Unknown Yes or No Yes or No Yes or No <br /> Emergency Stop Switch <br /> What is the location of the e-stop? <br /> IN=Inside 8uilding/Kiosk <br /> BUILD=Outside on the Building <br /> DISP=Outside in the Fueling(dispenser)Area <br /> TANK=Outside near the Tank Fill <br /> ,.(Circle ALL that apply) <br /> IN BUILb DISP TANK <br /> 11—d 01/14/2016 Page 4 of 4 <br />