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Section 4: Containment Sump and Dispenser Inspection (cont’d.) 4.b. Dispenser Inspection

[ ] Applicable [ ] Not Applicable

#

Answer (P)ass, (PC), (F)ail or (NA) for

Dis . #

Dis .#

Dis .#

Dis #

Dis #

1

2

2a.

3.

4

5

6 6a

.

each dispenser Dispenser in good condition and properly secured to pump island. Shear valve (pressure system) properly secured and shear section within ½” of top of pump island or manufacturer specifications. Fusible link or other thermally actuated device properly connected. Shear valve (Stage II piping) properly secured and shear section within ½” of top of pump island by manufacturer specifications or with flex connector. Dispenser hose in good condition with no cuts, or holes and equipped with breakaway device. Dispenser hose properly secured and not subject to damage from vehicle traffic (hose retractor). Emergency shut-off present.

Emergency shut-off properly identified.

(Circle one)

(Circle one)

(Circle one)

(Circle one)

(Circle one)

Y/N

Y/N

Y/N

Y/N

Y/N

Dispenser passes inspection. Questions 1 – 7 and 9 are (P) or (PC) Note: If the answer to any question is (F), explain below. List any problems noted during inspection. Note corrections.

If more then 5 dispensers include additional copies of this page.

Comments:

6b.

Emergency shut-off in correct location.

7 8

9

Dispenser is not leaking product.

Flex connector observed under dispenser..If in contact with soil, complete Section 8. Marina Hold open device has been removed from nozzle.

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Form Number: MDE/WAS/COM.055 Date: April 3, 2007 TTY Users: 800-735-2258

Facility I.D.

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