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Home My WebLink About18156 018770 051 07-25-2024 LSTEST AEPACS LIQUID SENSOR TEST Digitally signed by: AEPACS Annual p Liquid Sensor Inspection and Date:2025.01.10 12:43:00-06:00 Reason:Submission Data Functionality Test (Form 564) Location:State of Alabama version 3.5 (Submission#: HQS-NWZC-M28GR,version 2) Details Submission Alias Annual Liquid Sensor Inspection and Functionality Test Submission ID H08-NWZC-M28GR Form Input Report Entry Submission Method for Test Results Upload PDF Copy ofADEM Annual Liquid Sensor Inspection and Functionality Test(Form 564) Is the submission in response to an Warning Letter Notice of Violation/Notice of Proposed Delivery Prohibition? No Site Information Site Name CIRCLE K#2709068 Permit Number(Facility ID Number) 23413-051-018770 Site Address 1167 HWY 14 MILLBROOK,AL 36054 United States Upload Test Results IIf your site uses Interstitial Monitoring as the sole method of release detectionfor both the Tanks and the Piping,the following two questions can be answered in lieu ofADEM Form 565 Does the site setup agree with the configuration shown in the ATG Console? Yes Is the ATG Console battery backup operational? Yes Test Results Tank Install Date Tank Product Tank Status Test Date Test Result 12/222022 54282 Unleaded gasoline Currently in Use 0725/2024 Pass 12222022 54283 Premium gasoline,Ethanol free gasoline Currently in Use 07252024 Pass 12222022 54284 On road diesel,Other Currently in Use 07252024 Pass 12222022 54284 On road diesel,DEF Cunently in Use 07252024 Pass 1/10/2025 12:43:00 PM Page 1 of 2 Attach the PDF file of the test form 27 068 n 72 2 24 R vi f 1 1 2 25 12: 7 PM Comment Revised Sensor Form attached. Revisions Revision Revision Date Revision By Revisions 12/6/20245:19 AM Mike Cukauskas ReAsion2 118/20252:06 PM Mike Cukauskas 1/10/2025 12:43:00 PM Page 2 of 2 Digitally signed by: AEPACS Annual Liquid Sensor Inspection and Date:2024.12.0605:26:03-06:00 q p Reason:Submission Data Functionality Test (Form 564) Location:State of Alabama version 3.5 (Submission#: HQS-N WZC-M28GR,version 1) Details Submission Alias Annual Liquid Sensor Inspection and Functionality Test Submission ID H08-NWZC-M28GR Form Input Report Entry Submission Method for Test Results Upload PDF Copy ofADEM Annual Liquid Sensor Inspection and Functionality Test(Form 564) Is the submission in response to an Warning Letter Notice of Violation/Notice of Proposed Delivery Prohibition? No Site Information Site Name CIRCLE K#2709068 Permit Number(Facility ID Number) 23413-051-018770 Site Address 1167 HWY 14 MILLBROOK,AL 36054 United States Upload Test Results IIf your site uses Interstitial Monitoring as the sole method of release detectionfor both the Tanks and the Piping,the following two questions can be answered in lieu ofADEM Form 565 Does the site setup agree with the configuration shown in the ATG Console? Yes Is the ATG Console battery backup operational? Yes Test Results Tank Install Date Tank Product Tank Status Test Date Test Result 12/222022 54282 Unleaded gasoline Currently in Use 0725/2024 Pass 12222022 54283 Premium gasoline,Ethanol free gasoline Currently in Use 07252024 Pass 12222022 54284 On road diesel,Other Currently in Use 07252024 Pass 12222022 54284 On road diesel,DEF Currently in Use 07252024 Pass 12/6/2024 5:26:03 AM Page 1 of 2 Attach the PDF file of the test form 9068-Sensor 07252024.odf-12/06/2024 05:20 AM Comment NONEPROVIDED 12/6/2024 5:26:03 AM Page 2 of 2 LSTEST ADEM ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST FOR YEAR 2024 Facility Name;C rcle K#2709068 Owner Address: ll 7 Address: City,County, Zip:Milbrodc ELMORE 36054 Cif 5[afE ;R'af 1100 NC 27606 Facility I.D.# Phone#:85()-316-6673 Tester Name:Andrew Parnell Tester Phone#: 800-964-1250 Tester'Company:T nkn n Test Date: 7/2 /2 24 Instructions 9. SudriiC a mmpleEed copy of€his farm within 30 dajs perfomurg test b- Glourrdwater Branch_PG Boe361463,Mankgom,w AL 361301463, a fax to: (334)27U5631,or emI to. USTcorrwl ancerdadem alatbgmaom. 2. This form allows you to reco i up to 6 ADEM Unique Tank Numbers aridlor Urspenser NurMels,assuming lhat the�a[tlity IB Number remaMs the same. 3. Inspection and Testing most be performed in accordance with a nationally recognized code of practice(such as PEI RP-12DO a equrvalenl)or Me manulaclaa's InsNtdions_ 4. Keep a copy ofthis testing for 3years. Qlresf"wrls on hcN€ocsai this form should be directed to the GrounclI Branch,U31 Compliance Unit at(334)270 5655 ADEM Unique Tank#or Dispersion Tank T1 Tank T1 Tank T2 Tank T2 Tank T3 Tank T3 Product Stored or Dispensed REGULAR REGULAR PREMIUM PREMIUM ETHANOL ETHANOL UST 0UST UST OUST UST Z UST Location of sensor sub pump sub pump Z sub pump sub pump Z sub pump sub pump Intermediate intermediate Imenmedlate intenmedrate imdrmedlate intermediate d€spenser dispenser d€spenser dipenser dispenser dispenser Is sensor Installed on tank or piping2 ✓tank tank tank tank tank lank piping ❑ i in 0 n ❑ tin 0 in ❑ i in Typeofsensor dlsmminanng(D)or D D D D D D non-0iscnmina4n ND4 ✓ND �1 RD Ll NO NJRD L✓ND ZND Is sensor positioned close m bottom at —ves yes yes yes yes yes bwest Point of Ire,sum or Lanka _no ❑no O no ❑no Ono ❑no Odes inspection of the sensor intlirate _yes yes yes yes yes yes sensor is undama ed? no ❑no Ono ❑no Ono no Upon sensor activation,is alarm mggered _yes yes yes yes yes yes - on the console ter ire Coosa ser5or4 no El no El no El no Ono El no I$sensor relayed to sent off the pump9 ✓ne E/J no Ohs E/J no Vnos Vnos When relayed sensor is activated.dues it —yes yes yes yes yes yes snu[an me pump? Inc Lao ❑no Llno L rm LJ no nfa P1his Llnra P1his Llnfa Lhva Does con sole lest nisloN lneludelest _yes yes yes yes yes. yes alarms4 Don't for el to dear lessalarms —no ❑no ❑no El ❑no ❑m Result of Sensor Test? 7 pass 0 pass 0 pass 0 pass 0 pass 0 pass (Must as g all applicable entena to pass.) _fall ❑fail ❑fad ❑fad ❑tall ❑tail Repairs Need" Date of Repair Description of any Repairs Tesfefs Signature: ADEM Form 564 LSTEST ADEM ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST FOR YEAR 2024 Frunlit Name;C rcle K#2709068 Owner Address: 11 7 Address:Environmental City,County, Zip_Milltxook ELMORE 36054 Cif 5[afE ;R'af 1100 NC 27606 Facility I.D.# Phone#=85()-316-6673 Tester Name:Andrew Parnell Tester Phone#: 800-964-1250 Tester'Company-T nkn n Test Date_ 7/2 /2 24 Instructions 9. SudriiC a mmpleEed copy of€his farm within 30 dajs perfomurg test b- Glourrdwater Branch_PG Boee61463,Montgomery,AL 361301463, a fax to: (334)27U5631,or emI to. USTcorrwl ance(dadEm alatbgmaom. 2. This form allows you to terrors up to 6 ADEM Unique Tank Numbers aridlor Urspenser Numbers,assuming lhat the�a[tITy ID Number remains the same. 3. Inspection and Testing most be performed in accordance with a nationally recognized code of practice(such as PEI RP-12DO a equrvalenl)or Me manulaclaa's InsNtdions_ 4. Keep a copy ofthis testing for 3years. Qm:sf ins on hcx€ocompete this form should be directed to the Groundwater Branch,U31 Compliance Unit at(334)270 5655 ADEM Unique Tank#or Dispenser Disp 11/12 'Disp 13/14 Disp 15116 Product Stored or Dispensed DST UST DST UST UST UST Location of sensor sub pump sub pump sub pump sub pump sub pump sub pump Intermediate Intemperate Imenmedlate Intenmedrate imermedlate intermediate d€spenser Zalispenser Zdraperser dispenser dispenser dispenser Is sensor Installed on tank or piping2 ✓tank tank tank tank tank tank piping 0 i in 0 n ❑ min ❑ in ❑ i ur Typeofsensor dlsaiminanng(D)or D D D D D D non-0mscdminalln ND4 ✓ND �1 RD LINO JRD JNO (J NO Is sensor positioned close m bottom at —ves yes yes yes yes yes bwest Point of tre,sum or tank? _no ❑no O no ❑no Ono ❑no Does inspection of the sensor intlirate _yes yes yes yes yes LJ yes sensor is undanna el? no ❑no Ono ❑no Ono ❑no Upon sensor activation,is alarm mggered _yes yes yes yes yes yes - on the console ter ire Coosa sem5or4 no ❑no ❑no ❑no ❑m ❑no I$sensor relayed to shut off the pump? no L✓J no Vna ❑nos Urn (Jos When relayed sensor is activated.dues it —yes yes yes yes yes yes smut an me pump? na LJna ❑no LINGLJro LJ re, _nfa Chia 0 nfa ❑nia ❑nia ❑iva Does console lest nisloN lnelude test _yes yes yes yes yes. yes ararms4 D.0 for at to dear lessalarms —no ❑no ❑no ❑no ❑no ❑m Result of Sensor Test? 7 pass 0 pass 0 pass ❑pass ❑pass ❑pass (Must as g all applicable entena to pass.) _fall ❑fail ❑fag [I fall ❑tall ❑tail Repairs Need" Date of Repair Description of any Repairs Tesfefs Signature: ADEM Form 564 LSTEST ADEM ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST FOR YEAR 2024 Facilit Name;C rcle K#2709068 Owner Address: ll 7 Address:Environmental City,County, Zip_Milbrodc ELMORE 36054 Cif 5[afE ;R'af 1100 NC 27606 FaI I.D.# Phone#=85()-316-6673 Tester Name:Andrew Parnell Tester Phone#: 800-964-1250 Tester'Company-T nkn n Test Date_ 7/2 /2 24 Instructions 9. SudriiC a mmpleEed copy of€his farm within 30 days perfomurg test b- Grourrdwater Branch_PG Box e01463,Montgomery,AL 361301463, a fax to: (334)270,5631,or emI to. USTcorrwl ance(dadEm alatbgmaom. 2. This form allows you to reco i up to 6 ADEM Unique Tank Numbers aridlor Dispenser Numbers,assuming lhat the�a[tITy ID Number remains the same. 3. Inspection and Testing most be performed in accordance with a nationally recognized code of practice(such as PEI RP-1206 a equrvalenl)or Me manulaclaa's Insmtt9ions_ 4. Keep a copy ofthis testing for 3years. Ulresf"wrls on hcx€ocompete this form should be directed to the Groundwater Branch,U31 Compliance Unit at(334)270 5655 ADEM Unique Tank#or Dispersion Tank T4 'Disp 1Y Disp 3I4 Dish 516 Disp 7l8 Disp 9I10 Product Stored or Dispensed Diesel DST UST DST UST UST UST Location of sensor sub pump sub pump sub pump sub pump sub pump sub pump Intermediate intermediate Imennedlate intennedrate imermedlate Intermediate d€spenser Zalispenser Zdraperser Zalisperser Z dispenser Z disperser Is sensor Installed on tank or pipingp ✓tank tank tank tank tank tank _piping 0 i in 0 n B piping B in 0 i in Typeofsensor dlsalminanng(D)or D D D D D D non-0iscnmina4n ND4 ✓ND �1 RD LlNO NJRD NJ NO ZND Is sensor positioned close m bottom at —ves yes yes yes yes yes la el Point oftre,sum or Lanka _no ❑no Ono ❑no Ono ❑no Does inspection of the sensor intlirate _yes yes yes yes yes yes sensor is undama ed? no ❑no Ono ❑no Ono no Upon sensor activation,is alarm tnggered _yes yes yes yes yes yes - on the console ter ire,Coosa sem5or4 no El no El no El no Ono El no I$sensor relayed to stint off the pump9 no L✓J no Vna L✓J no Vnos Vnos When relayed sensor is activated.dues it —yes yes yes yes yes yes snu[an me pump? Inc Lao ❑no Llno L rm L ou, _nfa Lima Lnra Lima Lnfa Lnva Does con sole lest nisloN lnelude test _yes yes yes yes yes. yes alarms4 Don't for el to dear leal alarms —no El El no El no ❑no Elm Result of Sensor Test? 7 pass L pass 0 pass L pass 0 pass L pass (Must as g all applicable entena to pass.) _fall ❑fall ❑€aft ❑fall ❑tall ❑tail Repairs Need" Date of Repair Descrfpeon of any Repairs Tesfefs Signature: ADEM Form 564 LSTEST ADEM ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST FOR YEAR 2024 Facili Name_ Owner: Girl Address: i Address:Environmental hated Services 1 G[ County, Zip:Millbrook ELMORE 36054 City. Stat tl0;Il 0 NC 27606 Facility I.D.#. Phone#:850-316-6673 Tester Name.Andrew Parnell Tester Phone#: 800-964-1250 Tester Company_Tanknoloov.Inc, Test Dale_ Instructions 1. Submit a mmplefetl mpy of this farm within 30 days of performing test m Groundwater Branch,PO Box 361463,Montgomery,AL 36130.7463, or tax to: (334)27D 5631,or email to. USTcomolance(dademalabamaoov. 2. This Fenn allows you to reeort up to 6 ADEM Unique Tank Numbers armor Dispenser Numbers,assuming that the Facility ID Number remains the same 3. Inspedlion and Testing most be pedomled in accordance will a naturally recognized mtle of prance(such as PEI RIP1200 or equwalem)or the manufaclumYs instructions_ 4. Keep a Dopy ofthistesting far 3 years. Queslbns on now to complete this form should be directed 10 the Groundwater Branch,UST Compliance Unit at(334)2705655 ADEM Unique Tank 9 or Dispenser 4 Tank T1 Tark T1 Tank T3 Tark T3 Tank T4 DIsp 1/2 Product Stored or Dispensed REGULAR REGULAR ETHANOL ETHANOL Diesel UST OUST UST OUST UST UST Location of sensor sub pump 7 sub pump 7 sub pump 7 sub pump 7 sub pump 7 sub pump intermediate intermediate intermediate intermediate intermediate intermediate dispenser dispenser dispenser dispenser dispenser Z dispenser Is sensor installed on tank or tank tank tank tank tank tank- DIDIFU ✓J 0101110 in ✓Jentire DIDIFIG ✓J piping Type of sensor discriminating(D)or LJ D B LD B LD D non-0iscriminatin ND? ®ND BIND END `_FIND END FIND Is sensor positioned close to bosom at 66 yes Z yes Z yes yes yes yes lowest point of the sump or tank? ❑no Lno Lno no no -no Does inspection of the sensoriudicate yes yes yes yes yes yes sensor is unti etl? Lino ❑no Cno -in c Lno Jno Upon sensoraclivalion is alarm I iggered yes yes yes 7 yes 7 ye s _yes on the console Tar the coned sensors ❑no ]no Cno ]no Cno ]no Is sensor relayed to snot off the pump? V no elnos LJ nos I nos LJ nos I nos When relayed sensor is adivated,dcesg yes yes yes yes yes yes sdshut ensorff is amp? Lin, Lno Lno ❑no Lno Lno ®Fla 21 wa 2 Fla 0 nla 2 Pis nla Bo es can sole test n ist0 fy rout ode test 7 yes yes yes yes V yes yes alarms? Dcnl for et to dear test alarms El no ono Cno Ono Cno ono Result of Sensor Test? 0pass ZI pass Lpass 0pass Vpass ZI pass {Must meet ail applicable crtena to pass.) El Fail -fall [fail El ban Lfail -tall Repairs Needed Date of Repair Description of any Repairs Testers Signature: ADEM Farm 564 LSTEST ADEM ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST FOR YEAR 2024 FacilityName_ Owner: Girl Address: i Address:Environmental hated Services 1 G[ County, Zip:Millbrook ELMORE 36054 City. 5tat dl ;Iffdf N00 NC 27606 Facility I.D.#. Phone#:850-316-6673 Tester Name.Andrew Parnell Tester Phone#: 800-964-1250 Tester Company_Tanknoloov.Inc, Test Dale_ Instructions 1. Submit a mmpleted mpy of this farm within 30 days of performing test m Groundwater Branch,PO Box 361463,Montgomery,AL 36130-1463, or tax to: (334)27D 5631,or email to. USTcomolance(dademalabamaoov. 2. This fern allows you to reeort up to 6 ADEM Unique Tank Numbers andlor Dispenser Numbers,assuming that the Facility ID Number remains the same 3. Inspection and Testing most be pertomled in accordance w1h a naturally recognized mtle of prance(such as PEI RP-1200 or equwalem)or the manufaclumYs instructions_ 4. Keep a Dopy ofthistesting far 3 years. Queslbns on now to complete this form should be directed 10 the Groundwater Branch,UST Compliance Unit at(334)2705655 ADEM Unique Tank 9 or Dispenser 4 Tank T1 Tark T1 Tank T3 TarkT3 Tank T4 DIsp 1/2 Product Stored or Dispensed REGULAR REGULAR ETHANOL ETHANOL Diesel UST UST UST UST UST UST Location of sensor sub pump 7 sub pump sub pump 7 sub pump sub pump 7 sub pump intermediate intermediate intermediate intermediate intermediate intermediate dispenser dispenser dispenser dispenser dispenser dispenser Is sensor ilutalled on tank or tank tank tank tank tank lank piping? ❑DIDIFU 0101110 CDIDIVO im C in ❑ l In Type of sensor discriminating(D)or D D D D D D non-0iscriminatin ND? ❑ND CND CND CND CND ❑ND Is sensor positioned close to bosom at L yes yes yes yes yes yes lowest point of the sump or tank? ❑no Cno no Cno no Cl no Does inspecfan of the sensor indicate yes yes L yes LJ yes L yes LJ yes sensor is undama etl? Lino ❑no Cno ❑no Cno ❑no Upon sensoractivalion,is alarm I iggered yes yes yes yes yes yes an me mnsale icr the coned sensor+ Cno Cno Cno Cno Cno Cno Is sensor relayed to snot off the pump? El nyeso Elnos C nos El El nos C nos ]nos When relayed sensor is activated,does yes yes yes yesyes-7— yes shut off the pump? Li ❑no Cna ❑no Cno Cno ❑Fla ❑wa CFla ❑wa CFla 7nla Do es can sole test n isto ryFuel ode test yes yes 7 yes 7 yes L te yes yes alarms? Dcnt for et to dear not alarms C no Ono Cna Ono Cno Cno Result of Sensor Test? ❑pass ❑pass C pass ❑pass C pass ]pass {Must meet ail applicable cr¢es,to pass.) El Fail ❑fail Cfair El ban Ctail Jtall Repairs Needed Date of Repair Description of any Repairs Testers Signature: ADEM Farm 564 LSTEST ADEM ANNUAL LIQUID SENSOR INSPECTION AND FUNCTIONALITY TEST FOR YEAR FacilityName_ Owner: Address: i Address:Environmental hated Services 1 G[ County, Zip:Millbrook ELMORE 36054 City. Stat N0;U 0 NC 27606 Facility I.D.#. Phone#:850-316-6673 Tester Name.Andrew Parnell Tester Phone#: 500-964-1250 Tester Company_Tanknology.Inc, Test Dale_ Instructions 1. Submit a mmplefed mpy of this farm wthin 30 days d performing test m Groundwater Branch,PO Box 301463,Montgomery,AL 36130.7463, or tax to: (334)27D 5631,or email to. USTcomolance(dademalabamaoov. 2. This Fenn allows you to recort up to 6 ADEM Unique Tank Numbers are for Dispenser Numbers,assuming that the Facility ID Number remains the same 3. Inspedion and Testing most be pertomled in accordance will a nationally recognized mtle of prance(such as PEI RIP1200 or equwalem)or the manufadureYs instructions_ 4. Keep a Dopy ofthistesting far 3 years. Quegiam on how to complete this form should be directed 10 the Groundwater Branch,UST Compliance Unit at(334)2705655 ADEM Unique Tank 9 or Dispenser 4 DIap 15/16 Product Stored or Dispensed UST UST UST UST UST UST Location of sensor sub pump 7 sub pump sub pump 7 sub pump sub pump sub pump intermediate intermediate intermediate intermediate intemedate intermediate dispenser Zdispenser Vdisperser ZdIspenser Z dispenser Z dispenser Is sensor ilutalled on tank or tank tank tank tank tank lank- DIDIFUpiping? ✓J 0101110 in ✓Jentire DIDIFIG ✓J piping Type of sensor discriminating(D)or LJ D B L D B L D D non-0iscnminalm ND? ®ND AND AND `_FIND END FIND Is sensor positioned close to bonom at 66 yes yes Z yes yes yes #vly-es Iowesl point of the sum or tank? ❑no Cno Cno no Cno Does inspection of the sensoriudicate yes yes yes yes yes sensor is undama etl? ❑no ❑no Cno Cnc Cno Upon senscraclivalion is alarm I iggereol yes yes yes yes yes on the mnme Tar the conedsenso" ❑no ]no Cno ]no Cno Is sensor relayed to snot off the pump? V nos I nos LJ nos I nos Eno When relayed sensor is adivated,dcesg yes yes yes yes yes shut off the pump? Ana Cnc Cna ❑no Cno ®no 21 wa 2 Fla 0 nla 2 Pis Bo es can sole test n istc fy lout ode test yes yes yes yes yes alarms? Dent for etto dear test alarms ❑no ono Cno [In Cno ono Result of Sensor Test? pass ZI pass L pass 0 pass V pass ZI pass {Must meet ail applicable crtena to pass.) El tan -fall [fair El ban Lfail -tall Repalrs Needed Date of Repair DescrtpCan of any Repairs Testers Signature: ADEM Farm 564