HomeMy WebLinkAbout12724 009491 101 12-14-2020 ATGTEST SLA AUTOMATIC TANK GAUGE TEST 71932.28 ATGTEST
ADEM ANNUAL TANK GAUGE TEST
REPORT FOR YEAR
Facility Name: Owner:
Address: Address:
City, County,Zip: City, State,Zip:
Facility I.D.#: Phone#:
Tester Name: Tester Phone#:
Tester Company: Test Date:
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,or fez to: (334)270-5631,or email to: USTcompliancettDadernslabarni .
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 Unique Tank#
Product Stored
Automatic Tank Gauge Console Test
Does console test history include test ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
alarms?(Don't forget to clear test alarms ❑ no ❑no ❑no ❑no ❑no ❑ no
Does site setup agree with configuration ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
shown in console? ❑ no ❑no ❑no ❑no ❑no ❑ no
Is battery backup operational? 0 yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑ no ❑no ❑no ❑no ❑no ❑ no
Testing results? 13 pass 13 pass O pass 13 pass 13 pass 13 pass
Must meet all applicable criteria to pass. [3 fail 0 fail 0 fail 0 fail 0 fail ❑fail
Probe and Float Test
Is probe free of residual buildup? 0 yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑ no ❑no ❑no ❑no ❑no ❑ no
Are cables free of kinks? 0 yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑ no ❑no ❑no ❑no ❑no ❑ no
Was shaft inspected and free of damage? 0 yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑ no ❑no ❑no ❑no ❑no ❑ no
Do ficats move freely? 0 yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑ no ❑no ❑no ❑no ❑no ❑ no
Does measured product and water levels in ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
tank agree with console levels? ❑ no ❑no ❑no ❑no ❑no ❑ no
Does actual product float level agree with ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
console product float level? ❑ no ❑no ❑no ❑no ❑no ❑ no
Does Overfill alarm activation level agree ❑yes 0 We ❑yes 0 n/a ❑yes 0 n/a ❑yes 0 n/a ❑yes 0 We ❑yes 0 n/a
with console? ❑ no ❑no ❑no ❑no ❑no ❑ no
Does actual water float level agree with ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
console water float level? ❑ no ❑no ❑no ❑no ❑no ❑ no
Does water alarm activation level agree with ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
console? ❑ no ❑no ❑no ❑no ❑no ❑ no
Testing results? 13 pass ❑pass O pass 13 pass 13 pass ❑pass
(Must meet all applicable criteria to pass.) 0 fall 0 fail 0 fall 0 fall 0 fall L ❑fail
Repairs Needed Date of Description of any Repairs
Repair
Tester's Signature:
ADEM Form 565