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Facility Inspection Form Facility#: BP 1-1195 Test Date: 12/01/94 Work Order No. 963222 Tank Area Dispenser Area Stage II Equipment Check till type General inspection: Check system type Coaxial: [ X] S U N/P Problem System Balance system:[ X] Dual Point: [ ] Impact valves: [ X] [ ] [ ] [ ] Assist system:[ l Conventional: [ ] Hoses and nozzles: [ X] [ ] [ ] [ ] Check hose type Type of assist R U M P D O Coaxial:[ X] Check tank type Tank# Check how determined Number of hoses per product: [ l [4] [ 2] [ 21 [ l [ ] Dual:[ ] Steel: [ ] [ ] Store manager: [ ] Number of dispensers per product: [ ] [21 [2] [ 21 [ ] [ ] S U N/P Problem System SW Fiberglass: [ X] [ ] Store tank chart: [ ] Meter Y N Face seals:[ Xl [ l [ l [ l DW Fiberglass: [ ] [ ] Technician: [ X] Calibration sticker present: [ XJ [ ] 08/30/93 Belows(Boot):[ X] [ ] [ l [ ] Cathodic prot.: [ ] [ ] Tank diameter: [ X] Vertical check valves: [ ] [ ] Date of last calibration: Belows(Springs):[ X] [ ] [ ] [ ] �nown: ( ] [ J Visual verification: [ ] Electronic monitors Sys light. Red: ( ] Green: [ ] Product Lines Y N Amp reading: Steel: [ J Suction: [ ] Electronic tank gauges present:[ X] [ l NOTE:If 6betglm tach is p—t.aauihe Fiberglass: [ X] Pressure: [ X] Type:_VEDEEROOT platev if—timmmtbecaW.W. Y N DW Fiberglass: [ l Operational:[ X] [ l Strike plate: [ X] [ ] Trench liner present: [ ] Electronic line monitors present:[ ] [ X] Note:If problem,list tank#&product Cathodic protection: ( ] Type: S U N/P Problem System(s) Unknown; [ ] Operational:[ J [ ] Fill Cover: [ X] [ ] [ ] [ ] Leak Detector Interstitual monitors present Fill cap: [ XJ [ ] [ ] [ ] S U N/P Tanks:[ l Fill cap seal: [ X] [ ] [ ] [ ] Upon arrival: [ X] [ l [ ] Lines:[ ] Drop tube: [ X] [ ] [ ] [ ] Replacement history Operational:[ ] ( ] Drop tube shield: [ l [ l [ X] [ ] System Type Serial number Other monitors present V/R Cover. [ ] [ ] [ X] [ l [sup ][ PLD ] ( 307900003` ] Type: V/R Cap: [ ] [ l [ X] [ l [UNLD ][ DLD l [ 11290---- J Operational:[ l [ J V/R Seat: [ l [ l [ X] [ ] [SUP ][ XLP ] [ 301925699 J Monitoring Wells V/R Dry Brake: [ ] [ ] [ X] [ ] [UNLD It XLD ] [ 103940341 ] S U N/P Step: [X] [ l [ ] [ ] [ 11 l [ Present-.[ Xl [ l [ l ] [ l Su np cover. Cas locked:[ Xl [ ][ X] [ ] [ ] [ ] [ ][ l [ l P Overfill: [ l [ l [ X] [ ] Containment System Problems:[ l [ l [ l Overspill: [ ] [ l [ X] [ ] Check one Type: Y N Drain mechanism: [ l ( ] [ X] ( ] Fill pipe spill containment: [ ] Waste Oil Monitors-Present: [ ] [ X] Ball float: [ l I ] [ l [ ] At both subpump&dispenser ends: [ J Type: Ball float length: [ ] [ ] [ l [ ] At subpump end only: [ ) Operational[ l [ l Swing joints(tank end) At dispenser end only: [ ] Oil Water Separator-Present:[ ] [ X] Flex_ [ ] Pipe [ ] Unk.- [ X] —— No containment_ -- I XX] --- ----- -- — Quality: ------ Legend: S-Satisfactory;U-Unsatisfactory_N/P-Not Present;Y-Yes;N-No;R-Regular;U-Unleaded;M_Midgrade;P-Premium;D-Diesel;O-Other — Comments: Nae:Ca m section is w be used a list nems which nmd immediate au-tion and are nems which canna be=W at the time this teat wu completed. -- - - — _—_ PLUS DROPTUBE 1 SPRING BROKE ON COAXIAL SUP ALL SPRINGS MISSING ON DROPTUBE W/O FILL HAS NO CAP NO SPILL CONTENMENT JUST DIRT a