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i ill 11` 1 V4 <br /> 0 <br /> Site Number ®ate <br /> �. Hosewas <br /> rax Manufacturer Modal Number Manufacturer Model Number Manufacturer Condlt7on <br /> Dispenser No.&Fuel CA-Callow CA-Callow E, <br /> Grade(Ir applicable) EW-Emco Wheaton EW-Emco Wheaton Are they Installed/mounted <br /> NA-Harco EBW ng properly <br /> (for li singledf gas HL-Heady Write Model Number in space provided HE-He Write Model Number in functlonl <br /> list HK-Huskyspace provided Please write is to <br /> I regular,2 mldgrade, HU=Husky Yes or No <br /> 3,4,5 diesel,etc) VST=Vapor <br /> OPW NA=None <br /> Syst• VST=Vapor Syst <br /> f US`s" 6%j A V ST Gue 5 Wet OU¢`{toe <br /> 2 U SQ' &- R is B, SS' If v le ca g W NE <br /> '3 4 S'- F-va QST i�vas K wp�9w� <br /> \4 V ST- tetra N VSA rvR_S j3 c A'qf.'ff <br /> OT evrz N US`T &U.& s w�uN� <br /> C V ST evo tnr is 'V sr Ev n S R k AI \love <br /> 7 v ST evQ W evra s3k- I *\I Y <br /> ST- Ev N V S r" e-va SRW- wA%i&_�z `! <br /> Eaa Canopy81111board Loorvoltage Other <br /> What Is the location of the e-stop? <br /> S=Arched Solar Panel A=Attached Is thane a Billboard an Does the aft have low Does the elte sell E-85,86 m <br /> IN=Inside Buon theKFo ld canopies <br /> F=Flat Non-Solar Deck F-Free Sten B20 or have an Electric Car <br /> BUILD=Outside on 8ua Building canopies are9 property? VoUege Emergency Shut- <br /> DISP=Outside in the Dispenser Area onsite? (for Data/CRIND Charging station? <br /> TANK-Outside near the Tank Figs NA=No Canopy NA-No Canopy Yes or No Intercom)? <br /> (Circle ALL that apply) Yes or No <br /> DISP TANK PO <br /> _T <br /> Issued 05/11/2017 Page 4 of 4 <br />