HomeMy WebLinkAboutFMC OLDWr 30 MUPeUnla Hwy a 8
9akerd Wd, Califomia 93308
Phone: 661 588 2777
Fax: 661 588 2786
MA
To: Bksfd Fire Dept
Fam 1352 -2171
Phones
Re: Mercy Southwest Hospital
Frmm Kelly Tackett
lDatec 7 -20-11
Pagem
CC:
O Urgent For Review Please Comment PhNme Reply Me" Recycle
Attached are monitor certification results. Please call if you have any questions.
Thanks.
Kelly
11/1 d 80D << IC :80 E- LO-IIOZ
MR, Inc.
66)0 Rosedale Hwy,, # B, Bakersfield, CA 93308 Phone (661) 588 -2777 Fax (66 1) 588 -2786
MONITORING SYSTEM CERTIFICATION
This form must be used to document testing and servicing of monitoring equipment, A separate cert icarion or r ,,,,,,: i,t. orcoared for each monitoringiy ym controlpanel by the technician who performs the work. A copy of this form rnust be prov dvO t,
the tank system owner /operator. Tice owner / operatot must submit a copy of this form to the local agency regulating USTwithin30daysoftestdate,
A. General Information
Facility Name: /01 ft7tlT/ Les Bldg No. _ - —
Sttc Address: - City: 49Lc4 14LJ _ zip.
Facility Contact Person: ` Contact Phone No,: t, / J-e
Make /Medea of Monitoring System: %ZS- r Qa 1 dGl/ 1"/'G l l/ /•f Date of Testing /Scrvicutg
B. Inventory of Equipment Tested /Certified 40,10 JX-- 1rjV41S-"
Check the a proprlate boxes to Indlealt specific equiCmant tn%»eetedhervlcedr
Tnnk ID: / a ../U u Tank ID; _
In Tink Gwging Probe. Model: O (n -Tan dAUging Probe. Model:
Annular Spice or V It Sensor. Model: e Annular tee ar Vault Sensor. Model.
Pryr Sensor(s). Model: 0 Piping Su /Trench Sensor(s), Model: f
O Fill Sump enser(%). Model; Q FIII Sump S -offs). Model:
0 Mechanical Line Leak Detector. Model: Mechanical L e Leak Detector. Model: _ l
O Electronic Line Le" Detector. Model; Electronic Llne eak Detector. Model:
Tank Overfill I High•Level Sensor, Modal• 0 'T'ank Overfill / - h -Level Sensor, Model;
O Other (specity (specify eQuijnimenl I a and model In Section E on Palo 2 , 0 Other (specIfy (specify e u tnent type and model in coon L ui,
Tank ID: Tank IDt ..._.__....._..
0 In -Tank Gauging Proba, Model: D In -Tank Gauging Pro M cl: -
0 Annular Ace or Vault Sensor, Model: 0 Annular Space or VAU) enser. odel; _..._
0 Piping Sum Trench Sensor(s), Model; O Piping Sump / Trench S ser(s). odci:
0 Fill Sump Sen (s), Model: 0 Fill Sump Sensor(s). Model;
0 Mechanical Line ak Detector. Model: Mechanical Line Leak Dcte to . Model
O Electronic Line Lra elector. Model- Q Bleotronic Lino Leak Detect Model:
0 Tank Overfill / High -L t Sensor, M M Tank Overfill I high -Leve a tor. Model:
Other (specify equipment a arid, c) in Section $ on Page 1). Q Other (specify equipme type d model in Secuou F. an Pa tc 2,
Dispenser [0: _ DDlspenser tD:
0 Dispenser Containment Sense Model: OO' Dispenser C7ain nl Scnsor(s). odel:
0 Shear Valve( %). QQ Shear Valve
0 Du enser Containment F at s an hain s . 00 Di enser Cnt Floats end C n (s).
Dispenser Iq; DDispenser ID.
0 Dispenser Contain ant Sensor(s), Mo I: Disp Scnsor(s), Modc
0 Shear Valve(s). CCl She(s).
b Ois enter Co inment Float a and Chain 00 Dix ontainment Floatfa and Chains
Page 1 or
aloniloring System Certification
Il /Z d BOA c< le 80 0Z-Lo -lloz
0. Results of Testing /Servicing
Software Version Installed'
Contolete the IMinwino checktictr
1'es No' is the audible alarm operational?
Yes O No" Is the visual alarm o rational?
Yes 0 No' Were all sensors visually ins ccted functionally tested. and confirmed operational?
i i Y'FS Q 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 U No" If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modam)
A operational?
Yes No' For pressurized piping systems, does the twbine automatically shut down if the piping secondary containmentN/A monitoring system detects a leak, fails to operate, or is electrically disconnected? If yes; which sensors initiate
positive shut -down? (Check all that apply) D Sump/Trench Sensors; O Dispenser Containment Sensors.
laid you confirm 20sitive shut -down due to leaks And sensor failure/disconnection? 0-Yes; Q No.
j Yes No" For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.c. noffON/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible at the tatflc
fill oint s and o erating properly? If so, at what percent of tank ca2acity does the alarm trig of? q0
Q 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 rc lacement parts in Section E below.
Ycs" No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
Product O Water, If yes, describe causes in Section E, below.
Ycs 0 No' Was monitoring sXstem se t- up reviewed to ensure proper settings? Attach set up re orts if applicable
Yes No" Is all monitorin a ui ment o erational er manufacturer's cifications?
N to Section E below, describe how and when these deficiencies were or will be corrected.
E. Comments;
Page 2 of 3 03/01
II /E d 90D << H:90 OZ- LO -IIOZ
F. In -Tank Gauging/ SIR /Equipment: Check this box if tank gauging is used only for inventury control,
Q Chock this box ifno tank gauging or SIR equipment is installed.
This section must be completed if in -tank gauging equipment is used to perform leak detection monitoring.
Com let_ the following checklist-
yes I No* Has all input wiring been inspected for proper entry and termination, inoludirtg testing forYes No* Were all tank gauging probes visually inspected for damage and residue buildup? Yes 13 No* Was accuracy of system product level readings tested?
Yes No* Was accuracy of system water level readings tested?
Ycs No' Were all probes reinstalled.properly?
Yes No* Were all items on the eg4ment manufacturer's maintenance checklist completed?
In the Section H, below, describe how and when these detlefencies were or will be corrected.
G. }i.,lne Leak Detectors (LLD): Check this box if LLDs are not installed.
C.mmnletP. tho fAllAwtna'h—LU.4,
faults?
O Yes No* For equipment gtart^up or annual egttlpment certification, was a leak simulated to verify LL.p performance?
NIA Check all that apply) Simulated leak rate: 3 g.p.h.; 0.1 g.p.h ; O 0.2 g,p.h.
Cl Yes No' Were ill LLDs confamed operational and accurate within regulatory requirements?
Ycs • U No* Was the testing apparatus properly calibrated?,
Yes Q No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
N/A
Yes No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
N/A
Q Yes O No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring aystem is disabled
N/A or disconnected?
Yes Q No* For electronic LLN, does the turbine automatically shut off if any portion of the monitoring system
N/A malfunctions or fails a test?
Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected?
NIA
O Yes Q No* Were all items. on the equipment manufacturer's maintenance checklist completed?
f In the Section H, below, describe how and when these deficiencies were or will be corrected.
kl, Comments:
Page 13 of 3 03/01
11/17 d 90D << zE :90 0z_z0_1102
SWRCB, Jwiuury 2000
Spill Ducket T"ting Report Form
Thisform is intendedfor ore by contractors perrorming annual testing of U37•spill containment structures. The completedfurs+ und
printouts from testa (rf applicable), should be prc,vided to the facility owner /operatorfor submittal to the local rvgulurury u,yetwv
1, FAUIL1TY INFORMATION
Facility Name: a7 Date ofTesting: _
Facility Address: 4'".9- - --
Facility Contact: Phone: 461 - --
Date Local Agency Was Notified ofTesting ;
Name of Local Agency Inspector (l(present during testing):
Z. TESTING CONTRACTOR INFORMATION
Company Name: S
Technician Conducting Test; Jlv,?Q ZF12E
Credentials': CSLB Contractor
14 [
CC Service Tech, D SWRCB Tank Tester Ather ADeci) f
License Number(s): _
3. SPIM, Tt1TrVVT TVRTiMtr 1NMUMATMN
Test Method Used: drostatic 0 Vacuum 0 Other
Test Equipment Used: Equipment Resolution:
Identify Spill Bucket (By Tank
Dumber, Stored Producl, etc,)J
1 / Z 3 4
Bucket Installation Type: irect Bury
0 Contained in Sump
0 Direct Bury
0 Contained in SuMR
0 Direct Bury
0 Contained in Sump
Direct Bury
0 Contained in Sum
Bucket Diameter:
Bucket Depth:
Wait time between applying
vacuum/water and start of test;
Test Stan Time (Tt):
Initial Reading (A,):
Test End Time (TF):
Final Reading (RP):
Test Duration (Tr - Tt):
Change in Reading (RF -Rt):
P&WFail Threshold or
Criteria:
Test Result: pass 0 Fail 0 Pass Fail D Pass 0 Fail Pass FaiI
Comments - (include information on realm made prior to tealinz and recommendedfollow . upforfailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
1 hereby certify that all the Infornmtlon contained In thb report Is true, accurate, and In pli compliance with legal requirement.%.
Teehn' 'era's Si ature: /u'r G %' ` — Date;
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirctimits
M,4%1 kP —^'A etrinry t
It /S d 80) << ZE :80 OZ- LO -110Z
Jr`"5 tor" '41i Lyr.
Monitoring System Certiflcatloa Form: Addetsdum for VacuurnMresmim Interstitial Susan LO 163.1, Ent. 11
L .Results of V uum/Pressl; m Monitoring Fgtdpment Tenting
This page should be used to document testing . and servicing of vacuum and pressure interstitial sensors, A copy ofthisformmustbeincludedwiththeMonitoringSystemCortifleationForm, which must be provided to she tank
system owner /operator. no owner /operator roust aubmit a copy of the Monitoring System Certification Form to thelocalagencyregulatingUSTsystemswithin30daysoftestdate.
Manufacturer: Model: Syst=Type: 0 Pressure; VicUU11)
Sensor ID
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fat
Cowpoaent(s) Monitored by ails Sensor,
Sensor Functionality Test Result: Pats; Fall interstitial Communication Test Result; Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Teat Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Scnzctr PuncdoWiV Teat Rrstda Fast: Vail tnteritit181 Cotnnwnicarion Teat' Result: [] Pass; Fail
Compoaent(s) Monitored by this Sensor:
Sensor Punctionalit Test Result: Pass; Frail interstitial Communication Test Result; Pass; [] F;c I
Component(s) Monitored by this Sensor:
Sensor f=unctionality Test Result: Pass; 0 Fail Interstitial Communicadon Test Result: Pass, Pint
Cornmacat(s) Moaitarod by t# U Semort
Sensor Functionaliry Test Result: Q Pecs; Pall Interstitial Communication Test Result: Pass; Fail
Component($) Monitored by this Sensor;
Sensor Functionality Test,Reault: Pass; Fail Interstitial Comrntinication Test Result: C7 Pass; Fail
Component(s) Monitored by this Sensor:
Suisse Futtctiattali Test RcAultt Pass; P411 %butt dtW Comnumicat .ion rest Ke$ult: p Past; Fai t
Component(3) Monitored by this senson
Sensor Funetlon!W Teat Result: Pass; Fall Interstitial Communication Test Result; Pass, Fail
How was luterstttiat commnniaadon vetined?
Leak Introduced at Far End ofIntersitial Spoke;' 0 Oar e; Visual Inspection', Other Describe in Sec. J, below)
Vaov= was restored to opernting levels in ail interstitial spacm Yes No (!f no, describe in Sec, J, below)
J. Comments;
Page of
if the sensor successfully detects a simulated vaouurn/prossure leak lntroduood in the interatitial space at the furthest point from the
sensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice.
ll /9 d 90D « ££ 90 oz- Lo-IIK
BSSR, Inc.
6630 Rosedale Hwy,, 0 H, Bakersfield, CA 933:78 Phone (661) 588 -2777 Fax (661) 585 -2786
MONITORING SYSTEM CERTIFICATION
rhts form must be used to document testing and servicing of monitoring equipment. A separate certiilcauo "1_.lrl >:it..,fi,l,
ore Um t r each monitoring aystem control panel by the technician who performs the work, A copy of this form must be pn:% ..:r.. r,
du tank system owner /operator. The owner /operator must submit a copy of this form to the local agency regulating L,!S 't' within 30 days of test date.
A. General Information
Facility Name: /%i Q!J
p
Bldg. Nu.
Site Address: zo- City: ziN: _..... -
Facility Contact Person: _ Contact Phone No.: L,_/ )I UZ -5-Y,7Z
Make/Model of Monitoring System: TLS 31 Date of Testing /Servicuig:
8. Inventory of Equipment Tested/Certified
Chick the R ro riste boxes to Indleate a ecina equipment Ine eeteNeerviced:
Tank ID: Tank ID:
n•Tmk Gauging Probe, o el: F .-/107 O In•7an Gauging Probe, Model:
nnular Space orpV,,ault .Sensor. Model: hU Q Annular ace or Vault Sensor. Model:
piping Sump/ 7P6* A/ Model: T t7 Piping Sun /Trench Scnsor(s), Model. _ r
F 11 Sump Sanaor(s), Model: Z.fO -7D Fill Sump S sor(a }. Model
O Mechanical Line Leak Detector. Model: Mechanical L c Leak Detector. Model:
0 Electronic Line Leak Detector. Model: Electronic Lin Leak Detector. Model,
0 Tank Overfill I High -Level Sensor. Model C3 Tank Overfill I igh - Level Sensor. Model: _
Other ("6(y equipment t e and modes in Section 13 on Page 2L Q other (specify e i meat c end model in Scc( «1r urr 1'.mr
Tzok ID: Tauk ID: _..... ....
In-Tank Gauging Probe. Model: In -Tank Gauging P bc. Madck
O Annular ece or Vault Sensor. Model: Annular Space or Va t Sensor, Mod
Piping $u !Trench Sensor(s), Model: El Piping Sump /Trench naor(s). el _
O Fill Sump S sor(,). Model: O Fill Sump Sensors }. 'ode);
Mechanical Lt a Leak Detector, Model: Q Mechanical Line Leak Dc clot. Model;
O Electronic Line eak Detector. Model: Electronic Line Leak Detec r. Model: _
Tank Overfill I Ht -Level Sensor. Model; Q Tank Overfill / High•Lcvel sor. Model: _ .......
O Other (specify eoui ent type and mode n Section E on Pate 2). Other (3pec_jhe a uipmenl pe d model in Seet oo I, w1 Pa ,. I
ul
Dispenser [D: utspenser w:
Q Dispenser Containment nsor(s Model: Dispenser Containm I Sensor(s). Model
Q Shear Valve($), 0 sheaf Valve(s).
U Dispenser Containment Flo and Chain(s). 0 Dispenser Conte mcnt Floats and air, s). _
Dispeatser ID: Dispenser ID:
Q Dispenser Containmc Sensors odel: Dispenser C ntainment Scnsar(s). Mo ci
Shear Velve(s).
and
O Shear Val (s).
O Dis enser Conte cot Floats halo a . Dis ens Containment Floats and Chains
Dispenser ID Dlspens ID:
D spcnscr P&kainmenl Scnsor(s). M el; enser Containment Sensor(s), Model:
Shear V vt(s). Cl r Velve(s). visoerserODispenserContainmentFloatsandChain Containment Floats and Chuin s . w
If the facility contains more tanks or dispenser , copy this form. Include information for every tank and dispenser at the facih y
C. Certification - 1 certify that the equipment Ideadfled In this documeat was Inspected /serviced In accunlauev %sith in(•
manuracturers' guldel(nes. Attached to this Cerdfleation Is Information (mg, manufacturers' checklists) necessary tu vrril tJu,: u,i)
information Is correct and a plot Plan showing the layout or monitoring equipment, r any equipment capable or gciivreting
reports, 1 have also attached a copy of the report;. (check elf char apply); O Sys ee ijj eta Y Align r iso1
Technician Name (print): Signature:
Certil•ication No.: a), ZT-O l ,X-d jP License. No.
Tcv ng Company Name.
A
e t Phone No.:Wl__
S Address: D ,G D! -l /7Gi y d `T _ Date of Testing /Sctvteult,... _7.
Page I of
Vionitoring System Certification
II /L d 80) « 80 OZ- LO -110i'
Kcsults 01"festing/Servicing
Vursion Installed:
ic the fallowhip- clieckj4t:
No" Is the audible alarm ope'rational?
Is the visual alarm operational? J No*
r No* Were all sensors visually inspected, functionally tested and confirmed operational?
Nu' Wcre all sensors installed at lowest point of secondary containment and positioned so shat athe'r--c-c*j-ui'pniew will
not interfere with their proper operation?
No• If alarms arc relayed to a remote juonitoii=tig station, is all conimu-nications c4uipment (e.g. modern)
A operational?
NO Fur pressurized piping systems, does the turbine automatically shut down if the piping secondary containment
N/A monitoring system detects a leak, fails to operate, or is electrically disconnected? Ifycs; which sensors initiate
ospositive , ositive shilt-down? (Chock all that apply) Sump/Trench Sensors; Dispenser Containment Sensors.
ouDidy— confirm positive shut-down due to leaks Anj sensor failure/disconnecdon? C3 Yes; Q No. T.- No- For tank systems that utilize the Monitoring system as the primary tank overfill warning device (I C no
Z) N/A mechanical overfill prevention valve is installed), is the overfill warning alarm visible and audible akthe tank
rill point (s) and opera tin properly? If so, at what percent of tank capacity does the alarm trigger?
Yes ZDNNo Was any monitoring equipment replaced? rf 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)
Q Product; CJ Water, If es describe causes•in Section E, below.
No" i Was nioriitoruig system set-u reviewed to ensure proper settings? Attach set up reports, if applicable2
No's I is all rnonjtori2 e uiprnent operationa] Ecr manufacturer's specifications?
Iji S(-ctU E below, describe how and when these deflIciencles were or will be corrected.
1:'. CU111111ents:
11/8 d
Page 2 of 3
80)
03N I
VC:20 OZ-ZO-110Z
F. In-Tank Gaugllrg /SIR Equipment: Check this box if tank gauguig is used only for inventory control.
U Check this box if no tank gauging or SrR erlilirmPnt it installed,
1'Itis section must be completed if in -tank gauging equipment is used to perform leak detection monitoring.
Conlulete the Mllnwinv PhPPtrltet.
Yes
Yes
NO
O NO*
Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
Were alI tank gauging probes visually inspected for damage and residue buildup?
Ycs No- Was accuracy ofsystem product level readings tested?
7clyes Q No' Was accuracy ofsystem water level readings tested?
es No" Were all probes reinstalled. properly?
Yes No" Were all items on the equipment manufacturer's maintenance checklist completed?
In the Section R_ helAw. riaerrihP h^— . -A .aril.- th www
G. Line Leak Detectors (LLD):
C:oinolete the followlna eharkliot!
heck this box if LLDs are not installed.
Yes No* For equipment start -up or annual equipment certification, was a leak simulated to verify LLD performance?
O N/A Check all that apply) Simulated leak rate: O 3 g.p.h.; Q 0.1 g.p.h ; 0.2 g.p.h.
Yes No* Were all LLDs confirmed operational and accurate within regulatory requirements?
Ycs O No" Was the testing apparatus properly calibrated? -
04Yes Cl NO For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
N/A
U Yes No* For electronic LLDs, does the turbine automatically shut oft' if the LLD detects a leak?
N/A
G Yes No* For electronic LLDs, does the turbine automatically shut oil' if any portion of the monitoring system is disabled
C2 N/A or disconnected?
Q Yes 0 NO For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system
N/A malfunctions or fails a test?
J Yes Q No' For electronic LLDs, have all accessible wiring connections been visually inspected?
N/A
U Yes No* Were all items.on the equipment manufacturer's maintenance checklist completed?
In the Section H, below, describe how and when these deflciencles were or will be corrected.
H. Comments:
Page 9 of 3 03101
11 /6 d 90) « bE :80 K_- 0_110Z
Monitoring System CertiJ3cad(W F rtn Addeotrim forWe, Un li°ra:i
InL
LC 161, Enc. !1s
1. Results of Ytuuuna?rtMUrV Monitoring Equipment Teadng
Th;x page should be used to document testing and servicing of vacuum and pressure interstitial sensors, A copy ofthisformmustbeIncludedwiththeMonitoringSystemCertificationForm, which must be provided to the tank
system ownerloperator,1%e owner /operator must submit a copy of the Monitoring System Certification Form to the
local agency regulating UST systems within 30 days of test date.
Manufacturer: 1 Modal.,
Sensor ID
Component(s) Montored by Ibis Sensor-
Sensor Functionality Test Result: Pass;
Componeat:(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass;
Component(s) Monitored by this Sensor-
Sensor Functionality Test Result: Pass;
Component(s) Monitored by tbsio Sensor:
Sea= Puxdao4igr Tar Result Pass:
Component(s) Monitored by this Sensor.
Sensor Purnetionality Test Resuit: Pass;
Componeat(e) Monitored by this Sensor;
Sensor Functionality Test Result: Pass;
Catnponeat(s) Monitored by oast $Cann
Sensor Punctiorialiry Test Resuit: 0 Pass;
Cornponent(s) Monitored by Oils Sensor-
Sensor Functionality Test.Resuit: Q Pass;
Components) Monitored -by this Sensors
S=sAr Fu=Uaaality Teac Rutilc: [3 Pout;
Component(s) KWtored by this Sensor:
Sensor Functionality Test Result: C] Pass;
How was imerstiWti comm atiov verined?
Ltak Introduced at Par End of Intersddal Space;'
Vacuum was reatot*d to operating leveb In sW tnterod
J. Comments;
Page of
if the sensor success Fully detects a simulated vamurn/prosswo loak introduced in the intorstitial apace at tho Furthest point 1'rorn the
sensor, vacuum/pressure has been demonstrated to be comrnunioaj ng throughout the interstice,
trE 80 OZ -LO -U OZ
80) «
11/01 d
Syswm'iype: Premure; VaCV6111
Fail Interstitial Communication Test Result: Pass: Fu)l
Pall Ihterathtial Cotttmunicadon Test Result; Pass; Fidl
Fail Interstitial Communication Test Result: Pass; Fail
Fait iacerstiW Catttmuni=on Test ResuiC [] Pass; F:u(
Fill Interstitial Communication Test Resuh: Pass; Fait
Pail Interriitial Communication Test Result; Pass; Fuzl
Vail interstitial Cotnmunleadon Test Result: Pass; C) Fail
Fail Interatitial Communication Test Result: PUSS: Fail
pall lnmrstidal CtimmuWcacian Test Result Pass: Fad
Pall
Oau e;
ial epami
Inmrstidai Communication Test Result: [] Pnss: F'ail
Visual Ina ection; Other (Describe in Sec. J, below)
Yea No (If no, describe in Sec. J, below)
Page of
if the sensor success Fully detects a simulated vamurn/prosswo loak introduced in the intorstitial apace at tho Furthest point 1'rorn the
sensor, vacuum/pressure has been demonstrated to be comrnunioaj ng throughout the interstice,
trE 80 OZ -LO -U OZ
80) «
11/01 d
s
l
i /69 System Certification
Addrem;
Ilnol .... ...
pus'. .. .......
gc.
ftOS'P . : ..:.::::::::::::::
VST Monitoring Site Plan
h
Nto map was dr vm:
r
T
1f you already have a diagram that, shows all required information, you may include, it, rather than this Pagc, with your
Monitoring System Certification. on your site plan, show the general layout of tanks and piping, Clearly identify
locations of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular
5- paces, s=ps, dispenser pans, spill containers, or other secondary containment teas; mechanical or electronic line, lebk
dctectors; and in -tank liquid level probes (if used for laak detection), In the space provided, note the date this Site Plan
as prepared.
Page ,,,_ of 01
UVOU
11/11 d 90) << SE eo Oz- LO -UOZ