Laserfiche WebLink
t <br />S/S #: Business Name: <br />Address: <br />Contractor: <br />Name of person completing test(s): <br />Signature: <br />Dealer's Signature: <br />lfl out this <br />form for each <br />annual <br />inspection <br />and keep on <br />file. <br />Check off each test when performed: <br />i. Shear Valve Inspections — Date: <br />w+s <br />rn w.wwne®rw® <br />2. Blending Valve Inspections — Date: <br />3. Q Leak Detector <br />Product <br />Model Leak Full Line Pressure(PSI) <br />Detector Open Max. 221Close Min. 26 <br />Simulated Line Leak Test <br />Inspection <br />Date <br />Pass Foil <br />Super <br />Unleaded <br />Unleaded <br />Diesel <br />Other <br />4. = Dispenser Meter Calibration Procedure: <br />?. Before starting calibration runs, wet the calibration can with product <br />product to storage. <br />2. Run 5 gallons with nozzle wide open into the can. Note gallons and <br />drawn, and return product to storage. <br />3. Run 5 gallons with nozzle one—half open into the can. Note gallons <br />inches drawn, and return product to storage. <br />4. 'if the volume measured in a 5—gallon calibration can is more than 6 <br />above or below the 5—gcllon mark, the meter requires calibration by <br />device repairman. <br />and return <br />cubic inches <br />and cubic <br />cubic inches <br />a registered <br />Date/tirne Nozzle # Product <br />Fast Flow Slow Flow <br />S ---Gal. Draft S --Gal. Draft <br />Gal. Cu.ln. Gal. Cu.ln. <br />Vol. Returned <br />to storage <br />Gallons <br />Calibration <br />Required? <br />YES*/NO <br />*Note date <br />of Calibration dt Device(s) used: <br />