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RECEIVED <br /> DP cu i o cquipment auirve)*0 <br /> JAN 1 $ 2018 <br /> Site Number �� D b Date ( 3��� <br /> .E AL HEALTH <br /> S Mmiyfecarrer y7dtodel fNnnber trlariufacarrer Medd Number Manufacturer Condition <br /> Dispenser No.&Fuel CA=Catlow CA=Catlow <br /> Grade(if applicable) EW=Emco Wheaton EW-Emco Wheaton Are they installed/mounted& <br /> (for li single hose gas E M <br /> -Healy Write odei Number In space provided HE E Healy <br /> Please write it In Write Model Number in � Prop" <br /> t regularr.,2 mklgrede, <br /> Ilonly HE <br /> -Husky HK=Hspace Provided Yes or No <br /> 2 <br /> 3,4,5 diesel,etc) VST-OVPW OPW NA=None <br /> Vapor Syst. VST-Vapor Syst. <br /> �st-- <br /> Lis <br /> U <br /> V's <br /> �--- j,511/- <-V <br /> Exr-9—y Stop <br /> ► ;0Z14 Billboard Low V~ 0dw <br /> Whet Is dre loradon of the a-stop? <br /> IN=Inside Building/Kiosk Howmany <br /> S=Solar Panels A=Attached Is there a Billboard on Does the site have Low Does the site sell E-85,86 to <br /> Budding BUILD-Outside on the Bung camas are F-Non-Solar F-Free Standing the property? Voltage Em 820 or have an Electric Car <br /> DISP=Outside In the D' (for Data!CRW Dh/i Charging Station? <br /> rspTank Area onsite? NA-No NA=Na Yes or No Intercom <br /> TANK=Outside near the Tank Fos �°Pl' COPY )? Yes or No <br /> L that appy) <br /> IN UI DISP TANK <br /> moil,-ii 19/nanm7 ��J Pane 4 of 4 <br />