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Site Plumber Date <br /> Nozzles Breakaways Nozzles <br /> Dispenser# Manufacturer Model Number Manufacturer Model Number Dispenser Breakaways <br /> P Manufacturer Model Number Manufacturer Model Number <br /> Dispenser No.&Fuel CA=Caaow <br /> EW=Emco Wheaton Dispenser No.&Fuel CA=Calow <br /> Grade(if applicable) W =me ow p EW=Emco Wheaton <br /> (for a single(rose gas HA=Harco EW=Emco Wt Grade(if applicable) CA=Callow <br /> Write Model Number HA=Harco <br /> list disp.#ordy HK=Husky HE=Healy cants Model Number {for a single hose gas Write Model Number EW=Emco Wt <br /> in space provided HK- <br /> 'i regular,2 midgrede HL=Healy HU=Husky in space provided Est disp.#only -Husky in space provided HE=Healy Write Model Numbs <br /> 3,4,5 diesel,etc) Opw OPW 'I regular,2 midgrade HL=Healy HU=Husky in space provided <br /> VST=Vapor Syst 3,4,5 diesel,etc) OPW OPW <br /> VST=Vapor Syst. <br /> 13 <br /> Y� J <br /> g <br /> Fq' i T <br /> d <br /> Tank Field <br /> Observation Price/ID Sign Canopy Basement Billboard <br /> Wells Other <br /> Quantity of Ooes the site has an Is the canopy Is there a basement, <br /> Observation Wells ID sign over 30 feet S=Arched Solar Panel Attached or Free crawl space or Is there a Billboard on the property? Does the site seg E-85.B6 to 820 or <br /> Write in number <br /> high F=Flat Non-Solar Deck Standing? underground bays? have an Electric Car Charging Station? <br /> NA=No Canopy <br /> LINK=Unknown Yes or No Yes or No <br /> Yes or No Yes or No Yes or No <br /> Emergency Stop Switch <br /> What is the location of the e-stop? <br /> IN=Inside Building/Kiosk <br /> BUILD=Outside on the Building , <br /> DISP=Outside in the Fueling(dispenser)Area <br /> TANK=Outside near the Tank Fill <br /> (Circle ALL that apply) <br /> 8 LD DISK TANK <br /> issued oan40016 <br /> Page 4 of 4 <br />