HomeMy WebLinkAbout12724 009491 101 12-14-2020 LSTEST SLA LIQUID SENSOR TEST 71945.11 LSTEST
ADEM
ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST
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 fax to: (334)270-5631,or email to: USTcomolianceCdadernslabanni .
2. This form allows you to record up to 6 ADEM Unique Tank Numbers and/or Dispenser 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
ADEM Unique Tank#or Dispenser#
Product Stored or Dispensed
UST UST UST UST UST ❑UST
Location of sensor sub pump sub pump sub pump sub pump sub pump ❑sub pump
intermediate intermediate intermediate intermediate intermediate ❑intermediate
dispenser dispenser dispenser dispenser D dispenser ❑dispenser
Is sensor installed on tank or ❑tank ❑tank ❑tank ❑tank ❑tank ❑tank
piping? ❑ in ❑ piping ❑piping ❑piping ❑piping ❑ piping
Type of sensor: discriminating(D)or ❑ D ❑ D ❑D ❑D ❑ D ❑ D
non-discriminating(ND)? ❑ ND ❑ ND ❑ND ❑ND ❑ ND ❑ ND
Is sensor positioned close to bottom at ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
lowest oint of the sum or tank? ❑no ❑ no ❑no ❑no ❑no ❑ no
Does inspection of the sensor indicate ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
sensor is undama ed? ❑no ❑ no ❑no ❑no ❑no ❑ no
Upon sensor activation,is alarm triggered ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
on the console for the correct sensor? ❑no ❑ no ❑no ❑no ❑no ❑ no
Is sensor relayed to shut off the pump? ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
❑no ❑ no ❑no ❑no ❑no ❑ no
When relayed sensor is activated,does it ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
shut off the pump? ❑no ❑ no ❑no ❑no ❑no ❑ no
❑n/a ❑ n/a 1 ❑n/a ❑n/a ❑n/a ❑ n/a
Does console test history include test ❑yes ❑yes ❑yes ❑yes ❑yes ❑yes
alarms?(Don't forget to clear test alarms ❑no ❑ no ❑no ❑no I ❑no ❑ no
Result of Sensor Test? O pass O pass O pass O pass O pass O pass
(Must meal all applicable criteria to pass.) Ofail ❑fail [3 fall ❑fail Ofail ❑fail
Repairs Needed Date of Repair Description of any Repairs
Tester's Signature:
ADEM Form 564