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i <br /> SHEAR VALVE OPERATION INSPECTION <br /> o <br /> Facility Name: Owner <br /> Address: Address M <br /> CL <br /> -v <br /> City,State,Zip Code: City,State,Zip Code: <br /> Facility I.D.#: Phone#: o <br /> Testing Company: Phone <br /> This data sheet is for inspecting shear valves located Inside dispensers.See PEI/RP1200 Section 10 for the inspection procedure. CU <br /> Product Grade <br /> n <br /> m <br /> Dispenser 1D# — <br /> w <br /> Shear ValveType(Product/Vapor) =' <br /> o' <br /> l Is the shear valve rigidly o i <br /> anchored to the dispenser box ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> frame or dispenser island? o <br /> 2.Is the shear section posi- M <br /> tinned between 1/2 inch above ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No <br /> or below the top surface of the <br /> dispenser island? °r <br /> 0 <br /> m <br /> 3.Is the lever arm free to move? ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑'No ❑Yes ❑No ❑Yes ON ❑Yes ❑No _ <br /> ❑NA ❑NA ❑NA DNA ❑NA ❑NA ❑NA ❑NA ❑NA <br /> m + <br /> 4.Does the lever arm snap shut ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No c <br /> the poppet valve? ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA <br /> 0 <br /> 5.Can any product be dispensed ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑Nowhen <br /> m <br /> closed?a product shear valve is ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA ❑NA, I <br /> o <br /> A"No"to Lines 1-4 or a"Yes"for Line 5 indicates a test failure, ly <br /> 5' <br /> Test Results ID Pass ❑Pass ❑Pass ❑Pass 13 Pass ❑Pass El Pass 11 Pass ❑Pass <br /> ❑Fail ❑Fall ❑Fail ❑Fail ❑Fail ❑Faii ❑Fall ❑Fall ❑Fall T, <br /> Comments: <br /> m <br /> rD °; <br /> un <br /> o <br /> l <br /> Tester's Name(print) Tester's Signature <br />