Permit City Telephone County Municipality Name Borough City Township Check each type of dispensing device on the premises and provide requested RemotePreset Maker CarOperated Maker CashO ID: 836520
Download Pdf The PPT/PDF document "DEPARTMENT OF LABOR INDUSTRY BUREAU OF ..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
1 DEPARTMENT OF LABOR & INDUSTRY BUREAU OF
DEPARTMENT OF LABOR & INDUSTRY BUREAU OF OCCUPATIONAL & INDUSTRIAL SAFETY Permit #: City: Telephone: County: Municipality Name: Borough City Township Check each type of dispensing device on the premises and provide requested Remote-Preset Maker: Car-Operated Maker: Cash-Operated Maker: Key-Operated Maker: Other (Specify Maker: Does console bear an Underwriters Laboratories, Inc. approval? Yes Will there be an attendant on duty whenever the station is open to the general public? Yes Yes Will the emergency control be installed at an Yes VKXWRϑGHYLFH" $YDULDQFHPD\QRWEHUHTXHVWHGRQYes Will operation instructions be conspicuously posted on Yes in the immediate vicinity of the attendant’s principal Yes LIBI-700 08-20 (Page 1 of 2) Will dispensing operations be in clear view of the Yes Will attendant remain within an “arm’s length” of remote FRQWUROVZKHQHYHUÀDPPDEOHRUFRPEXVWLEOHOLTXLGVDUHYes :LOODWZRZD\ ³KDQGVRϑ´YRLFHFRP
2 PXQLFDWLRQVYes Will hose nozzle
PXQLFDWLRQVYes Will hose nozzle valves of gasoline dispensing devices be of an approved automatic-closing type? Yes Will parking spaces between the attendant’s principal designated “For Cars Only (No Vans, Trucks, or SUVs)”? Yes Yes Persons (other than attendants) using a “hold-open” point during the refueling operation. Yes Yes 9HKLFOHPRWRUVPXVWEHWXUQHGRϑZKLOHUHIXHOLQJYes Will each dispensing island have signs, conspicuously posted with letters at least By signing this form, I acknowledge that I understand that approval of this installation is contingent upon compliance with all requirements (including any UHODWHGWR¿QDQFLDOUHVSRQVLELOLW\IRXQGLQ3HQQV\OYDQLDVWDWXWHRUUHJXODWLRQDQGDOLVVXHGE\the Department of Labor and Industry.Company: City: Telephone: INSTALLATION SPECIFICATIONS Department of Labor & Industry | Bureau of Occupational & Industrial Safety | Boiler Division 651 Boas Street | Room 1614 | Harrisburg, PA 17121-0750 | 717.787.3806 | Fax 717.705.7262 | www.dli.pa.gov LIBI-700 08-20 (Page 2 of 2)