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APPENDIX C-10
SHEAR VALVE OPERATION INSPECTION Facility Name:OwnerAddress:AddressCity, State, Zip Code:City, State, Zip Code:Facility I.D. #:Phone #:Testing Company:Phone #:This data sheet is for inspecting shear valves located inside dispensers. See PEI/RP1200 Section 10 for the inspection procedure.Product GradeDispenser ID#Shear ValveType (Product/Vapor)1. Is the shear valve rigidlyanchored to the dispenser boxframe or dispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No2. Is the shear section posi-tioned between ½ inch aboveor below the top surface of thedispenser island? Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No3. Is the lever arm free to move? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA4. Does the lever arm snap shutthe poppet valve? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA5. Can any product be dispensedwhen the product shear valve isclosed? Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NA Yes No NAA “No” to Lines 1-4 or a “Yes” for Line 5 indicates a test failure.Test Results Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass FailComments:Tester’s Name (print) ___________________________________ Tester’s Signature _______________________________________________CHEVRON1125 COFFEE RDBAKERSFIELD,CABSSR INCDIESEL11-12PRODUCT4/2/25 REPLACEMENT OF SHEAR VALVE DUE TO LEAKNATHAN HOLMAN8111067