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�� PEI/RP1 200-17 APPENDIX C-11 EMERGENCY O• SWITCH OPERATION Facility Name: Owner: Address: Address: CN State,Zip Code: City,State,Zip Code: Facility I.D.#: Phone#: Testing Company: Phone#: Date: This procedure is to verify the operation of all emergency stop switches/buttons(Estops).Each Estop must disconnect power to dis- pensers,submersible turbine pumps(STPs)and all non-intrinsically safe electrical equipment in classified areas.Test each E-stop sepa- rately.See PEI/RP1200 Section 11 for the inspection procedure. Estop Number or ID Location 1. E-stops labeled and located ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No where easily accessible? 2. System fully powered and in ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑Nc ❑Yes ❑No normal operating condition? 3. After activating E-stop,power disconnected from: 3a. All dispensing devices ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No []Yes ❑No on all islands? 3b. All STPs for all fuel ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No grades? 3c. All power,control and signal circuits associat- ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ed with the dispensing devices and the STPs? 3d. All other non-intrin- sically safe electrical equipment in classified ❑Yes ❑No ❑Yes ❑No []Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No areas surrounding fuel dispensing devices? 4. All intrinsically safe electri- cal equipment remains ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No energized after E-stop acti- vation? 5. After testing, E-stop has been reset and power rees- ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No ❑Yes ❑No []Yes ❑No []Yes ❑No tablished to normal operat- ing condition? A"No'to lines 3a-3d indicates a test failure. Test Resutts ❑Pass ❑Fail ❑Pass ❑Fail ❑Pass ❑Fail []Pass ❑Fail ❑Pass ❑Fail []Pass ❑Fail Comments: Tester's Name(print) Tester's Signature 0 pei.org