HomeMy WebLinkAbout12725 015060 101 12-01-2019 ATGTEST QMV AUTOMATIC TANK GAUGE TEST 62342.12 b
e .. a.
AN1JUAGRELEgSE DETEC7ul 1dN EQU�PrylE1T TESTINGLC�FOREAR `
,Q iiohs bnhory to'cafipfete this {'s odbedi"edjoi-e GFouridwa(�e`r@rAncb,UST cbmprsnce Secgbn a`j 3¢)2-/{I.5855,
Facilit Name: r Owner:
Address: Address:
Ci , Coun Zi : City, State, Zip:
Facili I.D.#: —� 61 Phone#:
Tester Name: Tester Phone#:
Tester Company:
Instructions
1. This form allows you to record up to 5 ADEM Unique Tank Numbers,assuming that the Faclllly ID Number remain the same.
2. Complete portion of form pertaining to type of equipment Impacted for each tank.
3. Inspection must be performed in accordance with a nationally recognized code of practice(such as PEI RP-1200,or equivalent),
manufacturers Instructions,orADEM requirements.
4. Keep a record copy of this inspection for 3 years.
ADEM Unique Tank#
Product Stored
Autofirratic Tank Gauge and Other Controllers 2
ets criteria f§h'ieets criteria ❑meets criteria ❑meets criteria El meets criteria 14N 3
Alarm test ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action
❑Na 1 ❑rife ❑ Na ❑Na ❑n/a
Bets criteria M'nrssfs criteria ❑meets criteria ❑meets criteria ❑meets criteria
System configuration verification ❑needs action ❑needs action ❑needs action ❑needs action O needs action J N t 3 2020
❑n/a ❑n/a ❑Na ❑n/a ❑Na
lJ'meels criteria l$nreets criteria ❑meets criteria ❑meets criteria ❑meets criteria t y
Battery backup test ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action C�
❑Na ❑rife ❑ Na ❑Na ❑Na
Tester's initials and date tested l{'de} )A—1 / / / I / / / I
Vacuum Pumps and Pressure Gauges
❑meets criteria ❑meets criteria ❑meets onteda ❑meets criteria ❑meets criteria
Proper communication with ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action
sensors and controller verification p Na ❑Na ❑Na ❑Na ❑Na
Proper gauge reading verlfication ❑meets criteria ❑meets criteria ❑meets criteria ❑meats criteria ❑meets criteria
(All pressure gauges should show a El needs action ❑needs action ❑needs action ❑needs action ❑needs action
positive reading and all vacuum gauges p n/a ❑rile ❑Na ❑ Na ❑Na
should show a n etive reading.)
Tester's initials and date tested
Hand-Held Electronic Sampling Equipment Associated with Groundwater and Vapor Monitoring
calibration and operation meets criteria ❑meets criteria ❑meets criteria ❑ meets criteria ❑meets criteria
Proper calib
oration needs action El needs action ❑needs action ❑needs action ❑needs action
❑We ❑Na ❑We ❑n/a I ❑Na
Testers inidals and date testetl
Other Component Tested:
Describe test ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria
❑needs action ❑needs action ❑needs action ❑needs action ❑needs action
❑his ❑rile ❑Na ❑rife ❑We
Testers Initials and data tested f / / f I / / / / / /
Other Component Tested:
Describe test: ❑meets criteria ❑meets criteria ❑meets miter's ❑meets criteria ❑meets criteria
❑needs action ❑needs action ❑needs action ❑needs action ❑needs action
❑n/a ❑Na ❑nfa ❑Na ❑Na
Testers initials and date tested
Re airs Needed Date of Repair Descri lion of--y Repairs
ADEM Form 561 03fill
PSTEST_
. . ... �: „_',. :, ,_.•:.r.. _ _<x'r�',` - = i=ADE101"�;-?:> N:k¢�s"�`� ''>#; r?�a���'�hn
- ANNU.Q.LPR9BEAND $ENSOR z,,,,, RERORMFONTAM,
• .Oueshons on lwwto cueAplete thigfaim:sToNd be`'tllreded lgfhniter9ranr`.h;llglco�n'IienceDmtat _ .270;5655e."yro •:.c
Facility Name: OX P D Owner.
Address: Address:
City, County,Zip: - - Cith State,Zip,
Facility I.D.#: Phone#:
Tester Name: Tester Phone#:
Tester Company:
Instructions
1. Submit a completed copy of this form within 30 days of performing lest to: Groundwater Branch,PC Box 301463 Montgomery,AL
36130-1463,or fax to: (334)270-5631,or email to: USToumnliance(diadernelabama.aov.
2. This form allows you to record up to 6 ADEM Unique Tank Numbers,assuming that the Facility ID Number remains the same.
3. Complete portion of form pedaining to type of equipment tested for each tank.
4. 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.
5. Keep a record copy of this testing for 3 years.
ADEM Unique Tank#or Dispenser If
Product Stated(NIA for dispenser) yY(:
Probes
Probe is free of residual buildup? Dyer' f3ye�- ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Floats move freely? 9-y ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Shaft inspected and free of damage? I1'Yes LJ'ys ❑yes ❑yes ❑yes ❑yes
El no ❑no ❑no ❑no ❑no ❑no
Cables free of kinks? 0-16S R#W ❑yee ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Alarm functioning property? 12159- dTEg— ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Result of Probe test? W-Pass ElInss ❑pass ❑pass ❑pass ❑pass
(Probe must meet all applicable criteria to pass.) ❑fall ❑fall ❑fail ❑fail ❑fail ❑fall
Testers initials and date tested / / / 1 / / / /
Sensors
Installed on tank or piping? ❑tank . ❑tank ❑tank ❑tank ❑tank ❑tank
❑piping ❑piping ❑piping ❑piping ❑piping ❑piping
Type of sensor. discriminating(D)or non- ❑D ❑D ❑D ❑ D ❑D ❑D
discriminating(ND)? ❑ND ❑ND ❑ND ❑ ND ❑ND ❑ND
Piping interstitial space open,or test boots ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
positioned,to allow product to enter sump ❑no ❑no ❑no ❑no ❑no ❑no
from primary piping? ❑NA ❑NA ❑NA ❑ NA ❑NA ❑NA
Are sensors positioned vertically ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
near bottom of the sump or tank? ❑no ❑no ❑no ❑no ❑no ❑no
Alaml functioning properly? ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑ no ❑no ❑no
Is sensor relayed to shut the pump off? ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Did the sensor test shut the pump off? ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Result of Sensor test? ❑pass ❑pass ❑pass ❑pass ❑pass ❑pass
(Sensor must meet all applicable criteria to pass.) ❑fail ❑fall ❑fail ❑fail ❑fail ❑fail
Tester's initials and date tested / / / / / / / I
Repairs Needed Date of Repair Description of any Repairs
ADEM Form560 03118