Loading...
HomeMy WebLinkAbout12730 009494 101 12-01-2019 ATGTEST QMV AUTOMATIC TANK GAUGE TEST 63482.08 z- l D - ANjdUAL IIELEgSE DETECTION EQUJPMENT TESTING��OG FOREA Q :r Queshons on hoVtto;co/fiplete this toims CZ be d12M2d to eGmundwzte5$UancS;tlST Cbmp�`iance$,; :b'na (33g)Z7Q 5855 Fncilit1 Name: Owner: Address: Address: Cik CO Zi : City, State,zip: Facilii I.D.#: J— Phone P. Tester Name: I Tester Phone V. Tester Company: Instructions 1. This form allows you to record up to 5 ADEM Unique Tank Numbers,assuming that the Facility ID Number remain the same. 2. Complete portion of form pertaining to type of equipment Inspected for each tank. 3. Inspection must be performed in accordance with a nationally recognized code of practice(such as PEI RP-1200,or equivalent), manufacturer's Instructions,or ADEM requirements. j N 13 2020 4. Keep a record copy of this inspection for 3 years.ADEM Unique Tank# a - I i [�C l' Product Stored Automatic Tank Gauge and Other Controllers W,afeets criteria Mosslats criteria 6mEets citeda ❑meets criteria ❑meets criteria Alarm test ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action ❑Na ❑Na ❑Na ❑n/a ❑Na eets criteria 13meets criteria DiMts cdteria ❑meets cite ria ❑meets crReda System configuration verification ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action ❑n/a ❑We ❑n/a ❑n/a ❑nla' Bineets criteria WPm— s criteria 3-meets criteria ❑meets criteria ❑meets criteria Battery backup test ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action ❑Na ❑rile ❑n/a ❑Na ❑Na Tester's initials and data tested s / 1 / I I / 1 / Vacuum Pumps and Pressure Gauges Proper communication with meets criteria ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria p ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action sensors and controller vedfcation p Na ❑n/a ❑n/a ❑Na ❑Na Proper gauge reading verification ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria (Ail pressure gauges should show a O needs actlon ❑needs action ❑needs action ❑ needs action ❑needs action positive reading and all vacuum gauges n/a ❑Na ❑Na ❑n/a ❑Na should show a ne ative readi Tester's Initials and date tested Hand-Held Electronic Sampling Equipment Associated with Groundwater and Vapor Monitoring Proper calibration and operation meets criteria ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria oration n needs action ❑needs action ❑ needs action ❑needs action ❑needs action ❑rile ❑Na ❑n/a ❑ n/a ❑Na Tester's inkials and data tested 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 ❑We ❑Na ❑Na ❑n/a ❑Na Tester's initials and data tested I I / / / / / / I I Other Component Tested: ' Describe test ❑meets criteria ❑meets criteria ❑meets criteria ❑meets cdleria ❑meets criteria ❑needs actlon ❑needs solicit needs action ❑needs action ❑needs action ❑Na ❑n/a ❑Na ❑Na ❑Na Tester's Initials and date tested I 1 1 I 11 1 I l I Re airs Needed Date of Repair Description of any Repairs ADEM Form 561 03/1B PSTEST ANNUA4ROBEANDSENS6RTESI f?EPO FOR YEAR?` r Ruestlons onhowtb cbmplefe`tNs forrp shoultl be tluactetl to the Gmdn � � - - _$w`eter$rahch UST Com ri'ance Umt at $4 2]n 6665 , Facilit Name: � Owner. Address: Address: City, Count ZI : City, State Zip: Facilit I.D.! I Phone#: Tester Name: Tester Phone#: Tester Company: Instructions 1. Submit a completed copy of this tone within 30 days of performing lest to: Groundwater Branch,PC Box 301483 Montgomery,AL 36130-1463,or fax to: (334)2705831,or email to: USTwmoliancemladem.alabama.aov. 2. This forth 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 Pertaining 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 manufacturers instructions. 5. Keep a record copy of this testing for 3 years. ADEM Unique Tank#or Dispenser# 1 p3 Product Stored(N/A for dispenser) feot- lfl Probes Probe is free of residual buildup? mH9 ❑yes ❑yes ❑yes ❑no ❑no ❑no ❑no ❑no ❑no Floats move freely? R�Yeg ®'yam ❑yes ❑yes ❑yes ❑no ❑no ❑no ❑no ❑no ❑no Shaft inspected and free of damage? W-Ygs s s ❑yes ❑yes ❑yes ❑no ❑no ❑no ❑no ❑no ❑no Cables free of kinks? ®-ye li 13199 ❑yes ❑yes ❑yes ❑no ❑no ❑no ❑no ❑no ❑no Alarm functioning properly? GSyes m-yesr t3+yer ❑yes ❑yes ❑yes ❑no ❑no ❑no ❑no ❑no ❑no Result of Probe test? 16ysint Mpliss m-pafs ❑pass ❑pass ❑pass (Probe must meet all applicable criers to pass.) ❑fail ❑fail ❑fall .❑fall ❑fail ❑fail Testers initials and date tested / / / / Sensors Installed on tank or piping? ❑tank ❑tank ❑tank ❑tank ❑tank ❑tank ❑piping ❑piping ❑piping ❑DIDInq ❑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 rima 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 Alarm 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 lest shut the pump off? ❑yes ❑yes ❑yes ❑yes ❑yes ❑ es ❑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 ❑fail ❑fall ❑fail ❑fail ❑fail Testers initials and date tested ! ! / / I / / 1 / / 1 1 Repairs,Needed Date of Repair Description of any Re airs ADEM Fornni 03/18