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APPENDIX A-3: SAMPLE FORM FOR ANNUAL DISPENSER INSPECTION CHECKLIST <br /> Go to wvvw.p&i.org1RP900 for an electronic version of this form. <br /> ID#: ANNUAL DISPENSER INSPECTION CHECKLIST Date: <br /> Category IDescription PEIRtP900 N/A Disp1 Disp2 Map Disp4 <br /> Initial Fuel Dispenser Inspection 8.5 <br /> All Dispensers All dispenser components are clean and dry 8.5.1 <br /> If dispenser sump is present,sump is dry 8.5.2 <br /> Fuel Dispenser Inspection 8.6 <br /> Visible piping and fittings show no signs of leaking 8.6.1 <br /> Piping in good condition 8.6.2 <br /> Dispenser containment sump free of trash and debris 8.6.5 <br /> All Dispensers Junction box(es)have covers, not corroded;conduit and intrinsically safe wiring in good condition 8.6.8 <br /> Flexible connectors not frayed,twisted, kinked or bent beyond manufacturer specifications 8.6.9 <br /> Shear valves operate freely and close completely TEST DATE: 8.6.15 <br /> Stage II piping functional or else capped and sealed at an elevation lower than the fuel dispenser 8616 <br /> island <br /> Dispensers Flex connectors and other metallic product piping are not in contact with soil or water or are 8617 <br /> Without Sums cathodically protected <br /> Any water or product removed and disposed of properly 8.6.4 <br /> Sump free of cracks,holes,bulges, or other defects 8.6.6 <br /> Dispensers With Penetration fittings intact and secured 8.6.7 <br /> Sumps Piping interstitials ace open to the dispenser sump or dispenser pan iopen double-walled piping 8.8.21 <br /> system and <br /> Piping interstitial space closed to the dispenser sump (closed double-walled piping system only) 8.6.22 <br /> Dispensers With <br /> Single-Walled Single-walled sump tested for integrity every 3 years TEST DATE: 8.6.18 <br /> Sumps <br /> Dispensers With If not continuously monitored or inspected annually,double- <br /> Double-Walled walled sump tightness tested every 3 years TEST DATE: 8.6.19 <br /> Sum s <br /> DESCRIBE ANY DEFICIENCIES HERE: <br /> PEI RP 9M Annual Dispenser Inspection Checklist Page_of_ <br />