The URL can be used to link to this page

Home My WebLink About18370 000062 101 11-21-2019 LDLTTEST QMV LINE AND LEAK DETECTOR TEST 62585.21 ()000(P2 — L D L-T -TCST LINETT ADEM .. .. LINE TIGHTNESS TEST REPORT puesticns on howl.complete this form should be directed to the Groundwater Branch,UST Compliance Unit at 334 29m-5665 Facilit Name: One Stop 72- Liberty Store Owner. Address: 1175 W South BIVO Address: City, County,Zip: Montgomery,AL Citir. State Zip: Facility I.D. I Phone#: . Tester Name:If RA.. HA ii. ''" '>>* - 11 Tester Phone* Tester Certification: FI-578188 I Certification Expiration: 10-22-21 Tester Com arr :Clemens Fuel Systems, n . Instructions 1. Complete this form,include ail are test data,and submit to: Groundwater Branch,PO Box 301463 Montgomery,AL 36130.1463, or fax to: (334)270-5631,or email to: USTmmolance(, ademalabama.gov. Test data must include waiting time between delivery and testing,start time,end time,recorded volume changes and times,correction factors and calculations,and calculated leak rate for every test performed or the submittal will not be accented. 2. This form allows you to record up to 6 ADEM Unique Tank Numbers,assuming that the Facility In Number and the test equipment remain the same. 3. The tightness test equipment used must be approved by ADEM. Visit the NWGIDE website at www.nwglde.org to view a list of releass/leak detection equomenUmethods that ADEM approves for use in Alabama. - 4. Testing must be performed In accordance with the manufacturer's instructions. S. Keep a record copy of this testing for 3 years. Reason for Test-circle all that applg nnual Testf-111ew Installation quired by ADEM Response to SIR Problem) Manufacturerofrest Equipment: EStabrooks - Model or version: Ezy line tester ADEM Unique Tank# Product stored PE 1 PE2 Premium Premium 2 Regular Diesel ®fiberglass ®fiberglass ®fiberglass ®fiberglass ®fiberglass ®fiberglass Piping material tested Ofleldble Oflexible Dflexible Dilatable Ora le Oflexible Osteel Dsteel Ostael Osteel Osteel Osteel Piping capacity (gallons) 10 G 1013 1013 10 G 10113 1013 Dne pressure during test 50 psi 50 psi 50 psi 50 psi 50 psi 50 psi (psi) Equipment thresholdsho6 -.05 -.OS -.05 -.05 -.05 -.05 h Measured leak rate-(oph) D O O O O 0 ®pass ®pass ®Pass ®pass - ®pass ®pass Results of test: Ofail Ofall OfaiI Ofail E3 Ofail Dinconclusive Clud.,mclusive Oinconclusive Oinconclusive Oinconclusive Oinconciusive Tester's initials and DH 11-21-19 D 11-21.1 DH 11-21-19 date tested DH 11-21-19 DH 11-21-19 DH 11-21-19 Repairs Needed Date of Repa Description of any Repairs Certification I certify under penalty of law that the test was performed In accordance with all regulatory requirements of ADEM administrative code rule 335-6-15 and that the submitted infornaton is true,accurate,and complete. Signature of Tester: ` - Date: 11-21-19 ADEM Form 477 ml 1110 m2(revised 3118) ADEM AUTOMATIC LINE LEAK.DETECTOR(ALLD) TEST.REPORT Questions on how to cdm fete this form should be directed to the Groundwater Branch,UST Compliance Unit at 334)270S555 FaciQ Name: One Stop 72- Liberty Store Owner: Address: 1175 W South Blvd Address: City, County,Zip: Montgomery City,State,Zip: Facili LD.#: Phone#: Tester Name: MllasRirdii 1 Tester Phoria#: 850-265-8881 Tester Certification: FL-578186 - Certification Expiration: 1 U-22-21 Tester Com an Instructions 1. Submit this form,attach all test data for every test performed,and submit a completed copy of this form to: Groundwater Branch,PO Box 301463 Montgomery,AL 36130-1463.or fax to: (334)270.5531,or email to: USTcomphance'Madem.alabama.cov. Thisform must be completed and included with the test data or the submittal will not be accepted. 2. This forth allows you to record up to 6 ADEM Unique Tank Numbers,assuming that the Facility ID Number and the test equipment remain the same. 3. Testing must be performed In accordance with a nationally recognized code of practice(such as PEI RP-1200 or equivalent)or the manufacturer's Instructions. 4. Automatic Line Leak Detectors are designed to be tested in-place. Do not remove and test outside the tank system. 5. Keep a record copy of this testing for a years. Test Method Used-circle: PEI RP-1200) 1^anufacturer) (ther(specify) Reason for Test-drele all that apply: IMnual Test) I New Installation)IV Required by ADEM) Manufaclurerof Test Equipment Estabrooks - Model orversion: EZY-3 leak dector ADEM Unique Tank# - - Product Stored Pet Pe2 Premium -Premium 2 Regular Diesel ®fiberglass ®fiberglass ®fiberglass 18fberglass ®fi erglass ®fiberglass Piping material tested Ofiemble flexible Dfiexible Oflexible Ofiexible Oflexible Dsted Dsteel Dsteal Osteel [lateral Defeat Approximate length of piping run tested 200 Ft 200 Ft - 200 Ft 200 ft 200 ft 200 ft nearest foot Type of ALLD ®mechanical IHmechanical ®mechanical ®mechanical ®mechanical ®mechanlcal Delectronic Oelectronic Delectronic Delectronic Delectronic Delectronic Line pressure 25 psi 25 psi 25 SI 25 Si 25 psi 25 psi Burin test i Measured leak rate(gph) 3 gph 3 gph 3 gigh 3 gigh 3 gph 3 gph ®pass - ®pass ®pass ®pass ®Pass ®pass Results of test Ofall Ofall ofail ofail Ofall Ofall Dinconclusive Oinecenclusive Olrrconclusive I Dinconctusive Dinconclusive Oinconclusive Tester's initials and date tested DH 11-21-19 DH 11-21-19 DH 11-21-19 DH 11-21-19 DH 11-21-19 DH 11-21-19 Repairs Needed Date of Repair Description of any Repairs Certification I certify under penalty of law that the test was performed in accordance with all regulatory requirements of ADEM administrative;code rule 335-6-15 and that the submitted information is true,accurate,and complete. SlgreWre of Tester — Date: 11-21-19 ADEM Form 551 ml 1110 m2(revised 3118)