HomeMy WebLinkAbout16276 015113 101 12-09-2020 LSTEST SLA LIQUID SENSOR TEST 52292.72 LSTEST
ADEM
ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST
FOR YEAR 2090
Facility Name: United Food and Fuel #11 Owner: McNeill Family
Address: 3801 Day St Address: PO Box 11
City, County,Zip: Montgomery, Montgonni 36108 City, State,Zip: Montgomery AL 36101
Facility I.D.#: Phone#: 334-263-9070
Tester Name: Kurtis Waites Tester Phone#: 334-300-0984
Tester Company: Ma or Oil Co Test Date: 12-9-20
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# 1 2 3
Product Stored or Dispensed
UST 91 UST 91 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 m 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)? RI ND ® ND 50 ND ❑ND ❑ ND ❑ ND
Is sensor positioned close to bottom at E yes ®yes ®yes ❑yes ❑yes ❑yes
lowest point of the sump or tank? ❑no ❑ no ❑no ❑no ❑no ❑ no
Does inspection of the sensor indicate ®yes RI yes KI yes ❑yes ❑yes ❑yes
sensor is undama ed? ❑no ❑ no ❑no ❑no ❑no ❑ no
Upon sensor activation,is alarm triggered ®yes Z 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 ID 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 R1 n/a ❑n/a ❑n/a ❑ n/a
Does console test history include test ®yes ®yes 3 yes ❑yes ❑yes ❑yes
alarms?(Don't forget to clear test alarms ❑no ❑ no 1 ❑no ❑no ❑no ❑ no
Result of Sensor Test? M pass ®pass M pass O pass O pass O pass
(Must meal all applicable cdleda to pass.) Ofail ❑fail [3 fall [3 fall Ofail [3 fall
Repairs Needed Date of Repair Description of any Repairs
Testers Signature: Kurtis Waites
ADEM Form 564