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S/S #: BUSINESS NAME: <br />Address: <br />Fill out this <br />form for <br />each <br />test when <br />performed: <br />each annual <br />CONTRACTOR: <br />inspection <br />Name of person completing tests: <br />Signature: <br />and keep <br />on file. <br />- Dote: <br />Dealer's Signature: <br />Check <br />off <br />each <br />test when <br />performed: <br />1. ❑ <br />Shear <br />Valve <br />Inspections <br />- Dote: <br />2. ❑ Leak Detector <br />Product Model Leak Full Line Pressure PSI Simulated Line Leak Test Inspection <br />Detector Open Max. 12 Close Min. 26 Pass Fail Dote <br />Regular <br />Supreme <br />Unleaded <br />Unleaded <br />Diesel <br />Other <br />3. ❑ <br />1. <br />2. <br />3. <br />4. <br />Dispenser Meter Calibration Procedure: <br />Before starting calibration runs, wet the calibration can with product <br />and return product to storage. <br />Run 5 gallons with nozzle wide open into the can. Note gallons and <br />cubic inches drown, and return product to storage. <br />Run 5 gallons with nozzle one-half open into the can. Note gallons <br />and cubic inches drawn and return product to storage. <br />If the volume measured in a 5-gollon calibration can is more than <br />6 cubic inches above or below the 5 -gallon mark, the meter requires <br />calibration by a registered device repairman. <br />Fast Flow Slow Flow <br />Date/Time Nozzle # Product 5-Gol. Draft 5 -Gal. Draft <br />Gal. Cu.ln. Gol. Cu.ln. <br />Vol. Returned Calibration <br />to storage Required? <br />gallons YES* NO <br />F*Note <br />date of Colibration & Device(s) used: <br />Cl EW.DWG <br />02-05-92 <br />Chevron <br />