HomeMy WebLinkAbout14765 013549 101 12-01-2019 ATGTEST QMV AUTOMATIC TANK GAUGE TEST 62845.84 b it
ANNUAL RE -igSE.DETECT N EQUfPMENT TF�STIN L OG FOR EAR,nr�
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Facili Name: ' i Owner:
Address: Address:
Coun Zi : City, State,Zip:
Facil' I.D.#. t? —Cs 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 Facility 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 RPA200,or equivalent), .
manufacturers Instructions,or ADEM requirements. 3 2�20
4. Keep a record copy of this Inspection for 3 years. H
ADEM Unique Tank# C
Product Stored
Automatic Tank Gauge and Other Controllers
affiiets criteria 04m rsds criteria ❑meets criteria ❑meets criteria ❑meets criteria
Alarm test ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action
❑Na ❑n/a ❑Na ❑Na ❑me
(4 meets criteria gil• mr€fs criteria ❑meets criteria ❑meets criteria ❑meets criteria
System configuration verification ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action
❑n!a ❑Na ❑Na ❑n/a ❑Na
mmeets cdteda &rriuets criteria ❑meets criteria ❑meets criteria ❑meets criteria
Battery backup test ❑needs action ❑needs action ❑ needs action ❑needs action ❑needs action
❑Na ❑Na ❑Na ❑Na ❑Na
Testers Initials and date tested
Vacuum Pumps and Pressure Gauges
Proper communication with meets criteria ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria
sensor; end controller verification needs action ❑needs action ❑needs action ❑needs action ❑needs action
❑n/a ❑me ❑n/a ❑ Na ❑Na
Proper gauge reading verification ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria
(All pressure gauges should show a 11 needs action ❑needs action ❑needs action ❑needs action ❑needs adlon
positive reatlingandellvacuumgaugas ONa ❑Ne ❑Na ❑n/a ❑n/e
should show a ne alive reatlin
Tester's initials and date tested 1 / / /
Hand-Held Electronic Sampling Equipment Associated with Groundwater and Vapor Monitoring
Pro er calibration and operation meets criteria ❑meets criteria ❑meets criteria ❑meets criteria ❑meets criteria
p ❑needs action ❑needs action ❑needs action ❑needs action ❑needs action
verification ❑We ❑We ❑Na ❑Na ❑Na
Tasters initials 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
❑Na ❑me ❑Na ❑n/a ❑n/a
Testers initials and date 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
❑Na ❑n/a ❑Na ❑n/a ❑We
Testers initials and date tested
Repairs Needed Date of Repair Descri tlon of any Repairs
ADEM Form 661 03118
PSTEST
y � ,ANNUAL RROBEANDSENSO�'��REPOR"�7' FO}�^Y�AR? �` 4°'���`
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Facili Name: � y"2' Owner.
Address: ) YJ'E7,rJ L: Address:
Cft , Count ,Zi ? �r T' 3 l Cit , state,Zi
Tester Name: Tester Phone
Tester Com an
Instructions
1. Submit a completed copy of this form within 30 days of performing test to: Groundwater Branch,PO Box 301463 Montgomery,AL
36130-1463,orfaxto: (334)270-5831,or email to: USTcanoliancelffadem.alabama.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 pertaining to type of equipment tested for each lank.
4. Testing most be performed In accordance with a nationally recognized code of pmctioa(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# v[.,
Product Stored(N/A for dispenser) A
t 1
Probes
Probe is free of residual buildup? U16s s ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Floats move freely? M- 9� ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Shaft inspected and free of damage? es a ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Cables free of kinks? M-Y45 ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no El no ❑no
Alarm functioning property? s s ❑yes ❑yes ❑yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Result of Probe test? 2F PMS 6:Wss ❑pass ❑ pass ❑pass ❑pass
(Probe must meet all applicable adhere to pass.) ❑fail ❑fail ❑fail ❑fail ❑fall ❑fail
Tester's initials and date tested -1® / / / / /
Sensors
Installed on tank or piping? ❑tank ❑tank ❑tank ❑tank ❑tank ❑tank
❑piping ❑piping ❑piping ❑pipinq ❑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
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 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 Q pass
(Sensor most meet all applicable aiterfa to pass.) ❑fall ❑fail ❑fail ❑fail ❑fail ❑fail
Testers initials and date tested / / / / / / I / I / / /
Repairs Needed Data of Repair Description of any Repairs
ADEM Form560 03/18