HomeMy WebLinkAbout5756 006292 081 08-04-2020 ATGTEST ALC AUTOMATIC TANK GAUGE TEST 57569.83 ATGTEST
ADEM ANNUAL TANK GAUGE TEST
REPORTFORYEAR
Fa call 111 Owner.
Address: >: o R Address:
Cit Court Zi ka CR , State Zi
Facili I.D.#: Z] *I — 4 2.9 i Phone#:
Tester Name: r Sid Hermd Tester Phone#: 334T45-0055
Tester CDm an : u um Environmental-AECT Test Date:
Iinstructions
1. Submit a wmplated copy at this form wimin 30 tlays of pedorming test to: Groundwater Branch,PO Box 301483,Montgomery,Al
36130-14a3.or fax tor. (334)270-5631.or email to: I isTcomphaneCf d bama 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. Inspection and Testing must be performed in accordance with a nationally recognized code of practice(such as PEI RP-1200 or
equivalent)or the manufacturers instructions.
4. Keep a copy of this testing for 3 years. Questions on how to complete this form should be directed to the Groundwater Branch,UST
Compliance Unit at(334)270-5655.
5. If the probe is not used for leak detection but the console is(e.g.double walled tanks using interstitial monitoring),then it does not
need to be tested.
ADEM UnI us Tank# S-
Product Storied . 40
Automatic Tank Ga a Console Test ❑yes 13 Yes
Does Console test history inGutle test yes Ayes ❑yes ❑yes Y
alarms? Don't to el to Gear lest alarms ❑m, ❑no no 13 no 13 no 0 no
Does site setup agree with configuration dyes Sg.Yes D Yes - D Yes
Y.
shown in console? ❑no ❑no ❑no ❑no ❑no ❑no
Is battery backup operational? R Yes Ryes y es ❑yes D Yes ❑yes
❑no ❑no ❑no ❑no ❑no ❑no
Testing results? pass 6pass Paso O Pasa 0 Pass Paas
Must meet all a Ilcable criteria to ass. fag ❑fail ❑fall ❑fail tall ❑tall
Probe and Float Test
¢Yes Yes ❑Yes ❑Yes ❑Yes D yes
Is probe free of residual buildup? ❑no ❑no ❑no ❑no ❑no ❑no
§I Yes to yes Oyes ❑yes ❑Yes ❑yes
Are cables free of kinks? no ❑no ❑no ❑no ❑no ❑no
❑yes Yes Oyu ❑yes ❑yes ❑Yes
Was shaft inspected and free of damage? no ❑no ❑no ❑no ❑no ❑no
9Yes $Yes ❑Yes ❑Yes ❑Yes ❑yes
Do floats move freely? no p no ❑no ❑no ❑no ❑no
Does measured product and water levels in R yes rd yes ❑yes D yes ❑yes D Yes
tank agree with console levels? ❑no ❑no ❑l ❑no ❑no no
Does actual product float level agree whin gryes 4D Yes ❑yes ❑Yes ❑yes ❑yes
console product float level? ❑no ❑no ❑no ❑no ❑no ❑no
Does Overfill alarm activation level agree ®yes❑Na M yes O Na ❑yes❑n/a ❑yes❑n/a ❑yes❑nla ❑yes D Na
with console? ❑no ❑no ❑no ❑no ❑no ❑no
Does actual water float level agree with pf.yes sO yes ❑yes ❑Yes ❑yes 0 yes
console water float level? ❑no ❑no ❑no ❑no ❑no ❑no
Does water alarm activation level agree with Ryes 9 yes ❑yes ❑yes ❑yes ❑yes
console? ❑no ❑no ❑no ❑no ❑no ❑no
Tasting results? p.pass Bpass ❑pass D pass O pass 0 Pass
(Must meet all applicable chlim to pass.) ❑fail 0 fail O fall O hil ❑tall ❑fall
Date of Description of any Repairs
Repairs Nseded Re air
Testees Signaturs:�
ADEM Form 565