HomeMy WebLinkAboutFMC 2015
2/21/07 1
Appendix VI
(Copies of Monitoring System Certification form and UST Monitoring Plot Plan available at http://www.waterboards.ca.gov.)
MONITORING SYSTEM CERTIFICATION
For Use By All Jurisdictions Within the State of California
Authority Cited: Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code of
Regulations
This form must be used to document testing and servicing of monitoring equipment. A separate certification or report must be prepared for
each monitoring system control panel by the technician who performs the work. A copy of this form must be provided to the tank system
owner/operator. The owner/operator must submit a copy of this form to the local agency regulating UST systems within 30 days of test date.
A. General Information
Facility Name: ________________________________________________________________________ Bldg. No.:___________________
Site Address: ________________________________________________ City: ________________________ Zip: ____________________
Facility Contact Person: ___________________________________________ Contact Phone No.: (_______)__________________________
Make/Model of Monitoring System: ________________________________________ Date of Testing/Servicing: ____/____/___________
B. Inventory of Equipment Tested/Certified
Check the appropriate boxes to indicate specific equipment inspected/serviced:
Tank ID: ____________________________________________
In-Tank Gauging Probe. Model: ____________________
Annular Space or Vault Sensor. Model: ____________________
Piping Sump / Trench Sensor(s). Model: ____________________
Fill Sump Sensor(s). Model: ____________________
Mechanical Line Leak Detector. Model: ____________________
Electronic Line Leak Detector. Model: ____________________
Tank Overfill / High-Level Sensor. Model: ____________________
Other (specify equipment type and model in Section E on Page 2).
Tank ID: ____________________________________________
In-Tank Gauging Probe. Model: ____________________
Annular Space or Vault Sensor. Model: ____________________
Piping Sump / Trench Sensor(s). Model: ____________________
Fill Sump Sensor(s). Model: ____________________
Mechanical Line Leak Detector. Model: ____________________
Electronic Line Leak Detector. Model: ____________________
Tank Overfill / High-Level Sensor. Model: ____________________
Other (specify equipment type and model in Section E on Page 2).
Tank ID: ____________________________________________
In-Tank Gauging Probe. Model: ____________________
Annular Space or Vault Sensor. Model: ____________________
Piping Sump / Trench Sensor(s). Model: ____________________
Fill Sump Sensor(s). Model: ____________________
Mechanical Line Leak Detector. Model: ____________________
Electronic Line Leak Detector. Model: ____________________
Tank Overfill / High-Level Sensor. Model: ____________________
Other (specify equipment type and model in Section E on Page 2).
Tank ID: ____________________________________________
In-Tank Gauging Probe. Model: ____________________
Annular Space or Vault Sensor. Model: ____________________
Piping Sump / Trench Sensor(s). Model: ____________________
Fill Sump Sensor(s). Model: ____________________
Mechanical Line Leak Detector. Model: ____________________
Electronic Line Leak Detector. Model: ____________________
Tank Overfill / High-Level Sensor. Model: ____________________
Other (specify equipment type and model in Section E on Page 2).
Dispenser ID: ________________________________________
Dispenser Containment Sensor(s). Model: ____________________
Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: ________________________________________
Dispenser Containment Sensor(s). Model: ____________________
Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: ________________________________________
Dispenser Containment Sensor(s). Model: ____________________
Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: ________________________________________
Dispenser Containment Sensor(s). Model: ____________________
Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
Dispenser ID: ________________________________________
Dispenser Containment Sensor(s). Model: ____________________
Shear Valve(s).
Dispenser Containment Float(s) and Chain(s
Dispenser ID: ________________________________________
Dispenser Containment Sensor(s). Model: ____________________
Shear Valve(s).
Dispenser Containment Float(s) and Chain(s).
*If the facility contains more tanks or dispensers, copy this form. Include information for every tank and dispenser at the facility.
C. Certification - I certify that the equipment identified in this document was inspected/serviced in accordance with the manufacturers’
guidelines. Attached to this Certification is information (e.g. manufacturers' checklists) necessary to verify that this information is correct
and a Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, I have also attached a
copy of the report; (check all that apply): System set-up Alarm history report
Technician Name (print): _________________________________ Signature: __________________________________________________
Certification No.: _______________________________________ License. No.: ________________________________________
Testing Company Name: _______________________________________________ Phone No.:(_______)_____________________________
Testing Company Address: ___________________________________________________________ Date of Testing/Servicing: ____/____/_____________
Monitoring System Certification Page 1 of 4 12/07
CIRCLEK#2708605
5600AUBURNST BAKERSFIELD 93306
TONYAPICENO (661)871-6273
TLS-350 11/11/15
UNLPREM UNL-MID
✔
✔
MAG-1 ✔MAG-1
✔
409 ✔409
208 ✔208
✔VL-LD2000 ✔VL-LD2000
✔DROPTUBEW/FLAPPER ✔DROPTUBEW/FLAPPER
UNLREG
✔MAG-1
✔
✔
409
208
✔VL-LD2000
✔DROPTUBEW/FLAPPER
1/2 3/4
✔
✔
BEAUDROW406 ✔
✔
BEAUDROW406
✔✔
JRODRIGUEZ JRODRIGUEZ Digitally signed by JRODRIGUEZ
Date: 2015.11.11 11:14:53 -08'00'
B37617/8004270 744619
IDECOInc.818 452-9931
7306ColdwaterCyn.STE7,NorthHollywood,CA91605 11/11/15
2/21/07 2
D. Results of Testing/Servicing
Software Version Installed: _____________________________________
Complete the following checklist:
Yes No* Is the audible alarm operational?
Yes No* Is the visual alarm operational?
Yes No* Were all sensors visually inspected, functionally tested, and confirmed operational?
Yes No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will not interfere with their
proper operation?
Yes No*
N/A
If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem) operational?
Yes No*
N/A
For pressurized piping systems, does the turbine automatically shut down if the piping secondary containment monitoring system
detects a leak, fails to operate, or is electrically disconnected? If yes: which sensors initiate positive shut-down? (Check all that apply)
Sump/Trench Sensors; Dispenser Containment Sensors. Did you confirm positive shut-down due to leaks and sensor
failure/disconnection? Yes; No.
Yes No*
N/A
For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no mechanical overfill prevention
valve is installed), is the overfill warning alarm visible and audible at the tank fill point(s) and operating properly? If so, at what percent
of tank capacity does the alarm trigger? ________%
Yes* No
Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or other equipment replaced and list the
manufacturer name and model for all replacement parts in Section E, below.
Yes* No
Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply) Product; Water. If
yes, describe causes in Section E, below.
Yes No* Was monitoring system set-up reviewed to ensure proper settings? Attach set up reports, if applicable
Yes No* Is all monitoring equipment operational per manufacturer’s specifications?
* In Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments:
___________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
_________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Monitoring System Certification Page 2 of 4 12/07
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MECHANICALOVERFILLISVALVEDROPTUBEWITHFLAPPPER.(SITEHASNO
EXTERIORATG,OVERFILL,AUDIBLE.FLAPPERSSERVEASOVERFILL)
✔
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328.03
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2/21/07 3
F. In-Tank Gauging / SIR Equipment: Check this box if tank gauging is used only for inventory control.
Check this box if no tank gauging or SIR equipment is installed.
This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring.
Complete the following checklist:
Yes No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
Yes No* Were all tank gauging probes visually inspected for damage and residue buildup?
Yes No* Was accuracy of system product level readings tested?
Yes No* Was accuracy of system water level readings tested?
Yes No* Were all probes reinstalled properly?
Yes No* Were all items on the equipment manufacturer’s maintenance checklist completed?
* In the Section H, below, describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD): Check this box if LLDs are not installed.
Complete the following checklist:
Yes No*
N/A
For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance? (Check all
that apply) Simulated leak rate: 3 g.p.h.; 0.1 g.p.h ; 0.2 g.p.h.
Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements?
Yes No* Was the testing apparatus properly calibrated?
Yes No*
N/A
For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
Yes No*
N/A
For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
Yes No*
N/A
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled or
disconnected?
Yes No*
N/A
For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system malfunctions or
fails a test?
Yes No*
N/A
For electronic LLDs, have all accessible wiring connections been visually inspected?
Yes No* Were all items on the equipment manufacturer’s maintenance checklist completed?
* In the Section H, below, describe how and when these deficiencies were or will be corrected.
H. Comments:
___________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
Monitoring System Certification Page 3 of 4 12/07
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IDECOInc.
TONYAPICENO
5600AUBURNST
CA 93306
11/11/15
CIRCLEK#2708605
BAKERSFIELD
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Page ____ of ____ SWRCB, January 2006
Spill Bucket Testing Report Form
This form is intended for use by contractors performing annual testing of UST spill containment structures. The completed form and
printouts from tests (if applicable), should be provided to the facility owner/operator for submittal to the local regulatory agency.
1.FACILITY INFORMATION
Facility Name: Date of Testing:
Facility Address:
Facility Contact: Phone:
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector (if present during testing):
2.TESTING CONTRACTOR INFORMATION
Company Name: IDECO INC.
Technician Conducting Test:
Credentials1: CSLB Contractor ICC Service Tech. SWRCB Tank Tester Other (Specify)
__________________License Number(s): 744619 License Type: C10 / A / HAZ
3.SPILL BUCKET TESTING INFORMATION
Test Method Used: Hydrostatic Vacuum Other: Visual Lake Test
(Specify)_____________________Test Equipment Used: Measuring Device Equipment Resolution: N/A
Identify Spill Bucket (By Tank
Number, Stored Product, etc.)
Bucket Installation Type: Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Direct Bury
Contained in Sump
Bucket Diameter:
Bucket Depth:
Wait time between applying
vacuum/water and start of test: N/A N/A N/A N/A
Test Start Time (TI):
Initial Reading (RI):
Test End Time (TF):
Final Reading (RF):
Test Duration (TF – TI): 1 hr. 1 hr. 1 hr. 1 hr.
Change in Reading (RF -RI):
Pass/Fail Threshold or
Criteria: 0.002 in. 0.002 in. 0.002 in. 0.002 in.
Test Result: Pass Fail Pass Fail Pass Fail Pass Fail
Comments – (include information on repairs made prior to testing, and recommended follow-up for failed tests)
Spill Box manufacture:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all the information contained in this report is true, accurate, and in full compliance with legal requirements.
Technician’s Signature:Date:
1 State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
OPW
CIRCLEK#2708605
5600AUBURNST
TONYAPICENO
JRODRIGUEZ
JRODRIGUEZ Digitally signed by JRODRIGUEZ
Date: 2015.11.11 11:16:37
-08'00'
✔
UNLPREMFILL
✔
11.5"
12"
9:00AM
11.5"
10:00AM
11.5"
60MIN.
0
✔
N/A
UNLMIDFILL
✔
11.5"
12"
9:00AM
11.5"
10:00AM
11.5"
60MIN.
0
✔
BAKERSFIELD
(661)871-6273
UNLREGFILL
✔
11.5"
12"
9:00AM
11.5"
10:00AM
11.5"
60MIN.
0
✔
✔
11/11/15
11/11/15
93306
ALARM HIST. CK# 2708605
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SYSTEM STATUS REPORT
ALL FUNCTIONS NORMAL
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IN-TANK INVENTORY
TANK PRODUCT VOLUME TC VOLUME ULLAGE HEIGHT WATER TEMP
1 UNL-PREM 3087 3047 6597 31.77 0.00 78.17
2 UNL-MID 2671 2630 7013 28.62 0.00 81.65
3 UNL-REG(005) 5781 5743 3903 51.18 0.00 69.03
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SYSTEM TYPE AND LANGUAGE FLAG
SYSTEM UNITS
U.S.
SYSTEM LANGUAGE
ENGLISH
SYSTEM DATE/TIME FORMAT
MON DD YYYY HH:MM:SS xM
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TANK PRODUCT LABEL
TANK PRODUCT LABEL
1 UNL-PREM
2 UNL-MID
3 UNL-REG(005)
4 87 UNLEADED
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TANK PRODUCT CODE
TANK PRODUCT LABEL
1 UNL-PREM C
2 UNL-MID B
3 UNL-REG(005) A
4 87 UNLEADED 4
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TANK FULL VOLUME
TANK PRODUCT LABEL GALLONS
1 UNL-PREM 9684
2 UNL-MID 9684
3 UNL-REG(005) 9684
4 87 UNLEADED 9816
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TANK DIAMETER
TANK PRODUCT LABEL INCHES
1 UNL-PREM 89.75
2 UNL-MID 89.75
3 UNL-REG(005) 89.75
4 87 UNLEADED 92.00
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TANK THERMAL COEFFICIENT
TANK PRODUCT LABEL
1 UNL-PREM 0.000700
2 UNL-MID 0.000700
3 UNL-REG(005) 0.000700
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ALARM HIST. CK# 2708605
4 87 UNLEADED 0.000070
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TANK MANIFOLDED PARTNERS
TANK PRODUCT LABEL SIPHON MANIFOLDED TANKS LINE MANIFOLDED TANKS
1 UNL-PREM NONE NONE
2 UNL-MID NONE NONE
3 UNL-REG(005) NONE NONE
4 87 UNLEADED NONE NONE
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TANK LOW PRODUCT LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-PREM 500
2 UNL-MID 500
3 UNL-REG(005) 500
4 87 UNLEADED 500
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TANK HIGH PRODUCT LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-PREM 9325
2 UNL-MID 9325
3 UNL-REG(005) 9325
4 87 UNLEADED 9325
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TANK OVERFILL LEVEL LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-PREM 8834
2 UNL-MID 8834
3 UNL-REG(005) 8834
4 87 UNLEADED 8834
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TANK HIGH WATER LEVEL LIMIT
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TANK PRODUCT LABEL INCHES
1 UNL-PREM 3.0
2 UNL-MID 3.0
3 UNL-REG(005) 3.0
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TANK MAXIMUM VOLUME LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-PREM 9684
2 UNL-MID 9684
3 UNL-REG(005) 9684
4 87 UNLEADED 9816
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TANK DELIVERY REQUIRED LIMIT
TANK PRODUCT LABEL GALLONS
1 UNL-PREM 981
2 UNL-MID 981
3 UNL-REG(005) 981
4 87 UNLEADED 981
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LIQUID TYPE
SENSOR LOCATION TYPE
1 87 ANNULAR TRI-STATE (SINGLE FLOAT)
2 87 TURBINE TRI-STATE (SINGLE FLOAT)
3 89 ANNULAR TRI-STATE (SINGLE FLOAT)
4 89 TURBINE TRI-STATE (SINGLE FLOAT)
5 91 ANNULAR TRI-STATE (SINGLE FLOAT)
6 91 TURBINE TRI-STATE (SINGLE FLOAT)
7 TRI-STATE (SINGLE FLOAT)
8 TRI-STATE (SINGLE FLOAT)
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TANK ALARM HISTORY
TANK 1 UNL-PREM
HIGH WATER ALARM JAN 5, 2012 10:30 AM
JAN 19, 2011 8:50 AM
OVERFILL ALARM JAN 5, 2012 10:34 AM
JAN 19, 2011 9:39 AM
LOW PRODUCT ALARM JAN 5, 2012 10:50 AM
HIGH PRODUCT ALARM JAN 5, 2012 10:34 AM
JAN 19, 2011 9:38 AM
INVALID FUEL LEVEL JAN 5, 2012 10:50 AM
JAN 5, 2012 10:27 AM
JAN 19, 2011 8:47 AM
PROBE OUT NOV 11, 2015 9:24 AM
MAY 12, 2014 1:26 PM
MAY 12, 2014 1:24 PM
HIGH WATER WARNING JAN 5, 2012 10:30 AM
JAN 19, 2011 8:50 AM
DELIVERY NEEDED MAY 31, 2012 9:44 AM
MAY 14, 2012 4:40 PM
APR 26, 2012 3:10 PM
MAX PRODUCT ALARM JAN 5, 2012 10:34 AM
JAN 19, 2011 9:41 AM
LOW TEMP WARNING MAY 7, 2014 3:07 PM
DEC 18, 2012 10:37 AM
JAN 19, 2011 8:47 AM
DELIVY DENSITY WARN APR 6, 2012 8:58 PM
TANK 2 UNL-MID
HIGH WATER ALARM JAN 5, 2012 10:38 AM
JAN 19, 2011 8:48 AM
OVERFILL ALARM JAN 19, 2011 9:26 AM
LOW PRODUCT ALARM JAN 5, 2012 10:28 AM
JAN 19, 2011 8:44 AM
JUL 20, 2010 10:03 AM
HIGH PRODUCT ALARM JAN 5, 2012 10:35 AM
JAN 19, 2011 9:28 AM
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ALARM HIST. CK# 2708605
INVALID FUEL LEVEL JAN 5, 2012 10:28 AM
JAN 19, 2011 8:45 AM
PROBE OUT NOV 11, 2015 9:24 AM
MAY 8, 2014 6:00 PM
DEC 18, 2012 10:35 AM
HIGH WATER WARNING JAN 5, 2012 10:31 AM
JAN 19, 2011 8:48 AM
DELIVERY NEEDED JUN 14, 2012 9:10 PM
MAY 8, 2012 10:22 AM
MAR 30, 2012 3:15 PM
MAX PRODUCT ALARM JAN 5, 2012 10:35 AM
JAN 19, 2011 9:31 AM
LOW TEMP WARNING DEC 18, 2012 10:36 AM
DEC 18, 2012 10:31 AM
JAN 19, 2011 9:40 AM
TANK 3 UNL-REG(005)
HIGH WATER ALARM JAN 5, 2012 10:41 AM
JAN 19, 2011 8:47 AM
OVERFILL ALARM MAR 31, 2014 11:20 AM
DEC 10, 2013 5:45 AM
JUL 21, 2013 5:48 AM
LOW PRODUCT ALARM FEB 27, 2015 1:36 PM
MAY 11, 2012 8:08 PM
HIGH PRODUCT ALARM JAN 5, 2012 10:36 AM
JAN 19, 2011 9:31 AM
OCT 20, 2010 8:05 PM
INVALID FUEL LEVEL JAN 5, 2012 10:29 AM
JAN 19, 2011 8:44 AM
APR 8, 2010 4:11 AM
PROBE OUT NOV 11, 2015 9:24 AM
DEC 18, 2012 10:34 AM
DEC 18, 2012 10:29 AM
HIGH WATER WARNING JAN 5, 2012 10:41 AM
JAN 19, 2011 8:47 AM
DELIVERY NEEDED MAR 8, 2015 9:15 PM
MAR 4, 2015 5:20 PM
FEB 27, 2015 10:58 AM
MAX PRODUCT ALARM JAN 5, 2012 10:36 AM
JAN 19, 2011 9:38 AM
AUG 27, 2010 11:15 PM
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ALARM HIST. CK# 2708605
LOW TEMP WARNING DEC 18, 2012 10:35 AM
DEC 18, 2012 10:29 AM
JAN 5, 2012 10:53 AM
DELIVY DENSITY WARN APR 6, 2012 8:50 PM
APR 5, 2012 9:13 AM
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LIQUID ALARM HISTORY REPORT
SENSOR LOCATION
1 87 ANNULAR
NOV 11, 2015 9:25 AM SENSOR OUT ALARM
NOV 11, 2015 8:05 AM FUEL ALARM
NOV 21, 2014 9:16 AM FUEL ALARM
2 87 TURBINE
NOV 11, 2015 9:25 AM SENSOR OUT ALARM
NOV 11, 2015 8:36 AM FUEL ALARM
NOV 21, 2014 9:00 AM FUEL ALARM
3 89 ANNULAR
NOV 11, 2015 8:09 AM FUEL ALARM
NOV 21, 2014 9:17 AM FUEL ALARM
NOV 21, 2014 9:10 AM FUEL ALARM
4 89 TURBINE
NOV 11, 2015 8:37 AM FUEL ALARM
NOV 21, 2014 9:04 AM FUEL ALARM
NOV 21, 2014 9:02 AM FUEL ALARM
5 91 ANNULAR
NOV 11, 2015 8:13 AM FUEL ALARM
NOV 11, 2015 8:13 AM FUEL ALARM
NOV 21, 2014 9:08 AM FUEL ALARM
6 91 TURBINE
NOV 11, 2015 8:38 AM FUEL ALARM
NOV 21, 2014 9:06 AM FUEL ALARM
MAY 15, 2014 1:58 PM SENSOR OUT ALARM
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661-871-7979
SMART SENSOR ALARM HISTORY REPORT
SENSOR LOCATION
1 DISP 1-2 AFM
2 DISP 3-4 AFM
3 DISP 1-2 VPS
MAR 28, 2011 10:24 AM COMMUNICATION ALARM
MAR 28, 2011 10:14 AM COMMUNICATION ALARM
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SYSTEM STATUS REPORT
ALL FUNCTIONS NORMAL
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SOFTWARE REVISION LEVEL
VERSION 328.03
Page 8
ALARM HIST. CK# 2708605
SOFTWARE# 346328-100-D
CREATED - 08.06.06.17.21
S-MODULE# 330160-004-a
SYSTEM FEATURES:
PERIODIC IN-TANK TESTS
ANNUAL IN-TANK TESTS
ISD
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