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SWRCB, January 2002 Page .{ of
j
Secondary Containment Testing Report Form
Thisform is intendedfor use by contractors performing periodic testing ofUSTsecondary containment systems. Use the
appropriatepages ofthisjorm to report resulisfor all components tested. The caompletedform, written testprocedures, and
printoutsfrom tests fifapplicable), shouldbeprovidedto ihefacility owner /operatorfor submittal to the localregulatory agency.
1. FACILITY INFORMATION
Facility Name: Date ofTesting:
Facility Address: / PfveI
Facility Contact: Phone:
I Date Local Agency Was Notified ofTesting:
Name ofLocal Aaencv Insoector (iforesent during testing)-
2. TESTING CONTRACTOR INFORMATION
Technician Conductina Test: I !Z _ I
Credentials: (CSLB Licensed Contractor U SWRCB Licensed Tank Tester
License Type: SS a I License Number. (
MaWacturer Training
Manufacturer Component(s) Date Traininje Expires
F3 4
3. SUMMARY OF TEST RF.S111T.TS
Component pass Fail Not
Tested Made
Repairloft
omponent pan Fail Not
Tested
Repairs
Made
W u u. u s u u u
u u u a, u u u
s L u u u to u u u
U u u u u u
u u u u u u
s u u u u u u
04 u u u u u u
2;S!3 M s u u U u u u u
U I u I u u u I u u
U u u u u U u
L u u u u u u u
2 s u u U U u u U
If hydrostatic testing was performed, describe what was done with the water after completion oftests:
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
To the best ofmy knowledge, thefacts stated in this document are accurate and infull compliance with legal requirements
Technician's Signature: Date: Asy —41" -c,
1
Test Method Developed By:
4. TANK ANNUL
Tank Manufacturer
Other (Sped)
TESTING
4.1.Industry Standard U Professional Engineer
Test Method Used: U Pressure
U Other (Spec')
U Vacuum J Hydrostatic
Test Equipment Used:
Ils Tank Exempt From Testing ?'
Tank #
U Yes U No
Tank #
U Yes U No
Equipment Resolution:
Tank # Tank #
U Yes U No U Yes U No
nk Capacity
Tank Material:
Tank Manufacturer.
Product Stored:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading (R,):
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF -RO:
Pass/Fail Threshold or Criteria:
s: $ ulf: . . U Pass U.Tail U. Ik saS U D;nii U Sass • U Fail I-1 A:alss• Up*0
Was sensor removed for testing? U Yes U No U NA U Yes U No U NA UYes U No U NA U Yes U No U NA
Was sensor properly replaced and
verified functional after testis ?
U Yes U No U NA
U Yes U No U NA U Yes U No u NA U Yes u No U NA
Comments — (include information on repairs made prior to testing, andrecommended follow -upjorjailedtests)
1 Secondary containment systems where the continuous monitoring automatically monitors both the primary and secondary
containment, such as systems that are hydrostatically monitored or under constant vacuum, are exempt from periodic containment
testing. (California Code of Regulations, Title 23, Section 2637(ax6))
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SWRCB, January 2002 Page oft.
S. SECONDARY PIPE TESTING
Test Method Developed By: U Piping Manufacturer Kindustry Standard U Professional Engineer
U Other (Spec)
Test Method Used: KPressure U vacuum U Hydrostatic
U Other (Spec)
Test Eauiriment Used: dw « a.,. «., Eauinment Resolution:
PipinEM "',r
Piping Material: W
I Piping" fliin * Wj— I Piping Rain # 's j_'Ij_'
I F
Piphi "g "Ruri
Piping Manufacturer. S
Piping Diameter: l"
Length of Piping Run: r
Product Stored:
Method and location of
i in -run isolation:
Wait time between applying
pressure/vacuum/water and
starting test
Test Start Time: r aj
Initial Reading (Ri): S
Test End Time:
Final Reading (RF):
Test Duration: I At 049
Change in Reading (Rrl?4): 19L g
Pass/Fail Threshold or,
Criteria 2
Test Result: • P6s U Fail h'1633 U Pall Pass U' iWI j 0 Pags U m
Comments — (include information on repairs made prior to testing, and recommendedfollow -upforjailed iesls)
Test Method Developed By. U Piping Manufacturer KlnduWy Standard U Professional Engineer
U Other (Sper(ly)
Test Method Used: Kpresstuv U vacuum U Hydrostatic
U Other (S )
Test Equipment Used:
Piping Material
Pipin nn is Pipin an Z
Equips Resohttion:
Plpin an n Plpin un
Pit
Piping Manufacturer
Piping Diairrter.
Length of Piping Run
Product Stored:
Method and location of
piping-run isolation
Wait time between applying
pressure/vacuum/water and
qta test
Test Start Time: r r r
Initial Reading M)+
Test End Time: 2-1 r
Final Reading (RF):
Test Duration:
Change in Reading (Rp -Rj:
Pass/Fail Threshold or
Criteria:
hest B sylt: J :' t t Faf! Ilia U I[PWI Pass LtFait UVau
Comments — (include informationon repairs madepriorto lea7in& andMao EM!Ledjollow- upforfalled tests)
Test Method Developed By: U Piping Manufacturer }Q Industry Standard U Professional Engineer
U other A"*)
Test Method Used: p<Pressrue U Vacuum U Hydrostatic
U Other (Spw#yr)
Test Equipment Used: 1r
Piping . 11n TS `ra
Piping Material: f? Ip
Equipment Resolution:
Tiping riping r
it
Piping Manufacturer: i r S
Piping Diameter. g'
Length ofPiping Run:
Product Stored:
Method and location of
in run isolation: TIC"
Wait time between applying
pressure/vacuum/water and
sbuting test
Test Start Time:
Initial Reading (Rr7
Test End Time:
Final Readin (RF):
Test Duration:
Change in Reading (RF -R,):
Pass/Fail Threshold or
Criteria: z
est$egalk. 7 . U Ball U iE:aii Pass U` liril 9 Paw U .
Comments — (wdude information on r+epatrs madepriorto testing, andrecovnnrendedfollow- +tpjorlaileid its)
o' e
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SWRCB, January 2002
Test Method Developed By:
Test Method Used:
Page 6 of
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6. PIPING SUMP TESTING
U Sump Manufacturer P4ndustry Standard U Professional Engineer
U Other (Sped)
Pressure U Vacuum Hydrostatic
06'er (Sped)
Test Equipment Used: 'J'S Equipment Resolution: 2-%
SUMP .#
Sump Diameter ' '
Sump # Sump # u Sump # -I*3
6' `
Sump Depth:
Sump Material:
es U No U NA
Was fail -safe verified to be
operational?*
Height from Tank Top to Top of
Highest Piping-Penetration: l " 14 & "
Yes U No
Height from Tank Top to Lowest
Electrical Penetration
Wait time between applying
pressure/vacuum/water and starting
test:
Test Start Time:
Z"
Condition ofsump prior to testing:.
Portion of Sump Tested' e Ail
Does turbine shut down when
sump sensor detects liquid (both
product and watery?'
Yes U No U NA , U No U NA $(Yes U No U NA XYcs UNo U NA
Turbine shutdown response time S 3 S
Is system programmed for fait -safe
shutdown ?'
KYes U No U NA Yes U No U NA Yes U No U NA es U No U NA
Was fail -safe verified to be
operational?*
KYes U No U NA Yes U No U NA S.Yes UNo U NA Yes U No UNA
Wait time between applying
pressure/vacuum/water and starting
test:
Test Start Time: t<14 t 2
Initial Reading (RO: o
Test End Time: f L2,4 z-, L
Final Reading (RF): 751 Y;4 DUO La y
Test Duration:
Change in Reading (RrRa: t i
Pass/Fail Threshold or Criteria:.
Test Results 4:1005- U FAf1 F'*,W -. 1k1ia(!I Ftu , 9; Pass U` Pok
Was sensor removed for testing? q Yes U No U NA K Yes U No U NA Wes U No U NA Yes U No U NA
Was sensor properly replaced and
verified functional after testing?
KYes U No U NA Yes UNo U NA 0,Yes U No U NA OLYes U No U NA
Comments — (include information on repairs madeprior to testin-e, and recommended folio% -up for failedtests)
tt Qj s v
7D
14961 Qs. // n emu. 01_Li4Pj,-sjR w 4 - -.1 zs—lj
i
Ifthe entire depth of the sump is not tested, specify how much was tested. If the answer to arty of the questions indicated with an
asterisk (') is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160)
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SWRCB, January 2002 Page 7 of
b_ PIPING WIMP TFCTiN(,
Test Method Developed By: U Sump Manufacturer )(Industry Standard U Professional Engineer
U Other (Spec)
Test Method Used: U Pressure U Vacuum `(Hydrostatic
U Ot:,er (Sped)
Test Equipment Used: = TS -S7'S
Sump # Sump # 1`
Sump Diameter: zq `' 2-q''
Equipment Resolution:
Sump # Sump #
Sump Depth: P. ql ,
Sump Material:
Height from Tank Top to Top of
Hi est Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration
Condition ofsump prior to testing:
Portion of Sump Tested oItoo o°
Does turbine shut down when
sump sensor detects liquid (both
product and water)?*
Yes U No U NA Yes UNo p(NA UYes U No U NA UYes U No U NA
Turbine shutdown response time G
Is system programmed for fail -safe
shutdown ?'
W Yes U No U NA U Yes U No XQNA U Yes U No U NA U Yes U No U NA
Was fail -safe verified to be
o rational ?'
Kyes U No U NA U Yes U No NAQ U Yes U No U NA U Yes U No U NA
Wait time between applying
pressure/vacuum/water and starting
test:
Test Start Time:
Initial Reading (Rj): It *7 24 71 E110.1ph,
Test End Time:
Final Reading (RF):
Test Duration:
Change in Reading (RF -Rj:
Pass/Fail Threshold or Criteria:
sTest:Resttlt:. rasa:' U` t it Pam : l l l ii LI: : "F'asa :. U Fatl U 1'aas U I
Was sensor removed for testing? 71(Yes U No U NA Yes U No U NA U Yes U No U NA U Yes U No UNA
Was sensor properly replaced and
verified functional after testing?
UKYesUNo NA Yes U No U NA UYes U No U NA U Yes U No U NA
Comments — (include information on repairs madeprior to testing, and recommendedjo!/ow -upjorjaiWtests)
1 Ifthe entire depth ofthe sump is not tested, specify how much was tested. Ifthe answer to gpy ofthe questions indicated with an
asterisk ( *) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LO -160)
1 .
SWRCB, January 2002
7.
Test Method Developed By:
Test Method Used:
Test Equipment Used:
ER- DISPENSER CONTAINMENT (UDC) TESTING
U UDC Manufacturer U Industry Standard U Professional Engineer
U Other (Spec)
Pressure U Vacuum U Hydrostatic
Other ( Speciy)
uipment Resolution:
UDC # I UDC # I UDC # I UL
e'
Page 9 of
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1
UDC Material:
UDC Depth:
Height from UDC Bottom to Top
of Highest Piping Penetration:
Height from UDC Bottom to
Lowest Electrical Penetration:
Condition of UDC prior to
testing:
Portion of UDC Tested
Does turbine shutdown when
UDC sensor detects liquid (both
product and water)?.
U Yes U No U NA U Yes U No U NA U Yes U No U NA U Yes U No U NA
Turbine shutdown response time
Is system programmed for fail-
safe shutdown ?'
U Yes U No U NA U Yes UNo U NA U Yes U No U NA U Yes U No U NA
Was fait -safe verified to be
o rational?'
U Yes U No U NA U Yes UNo U NA U Yes U No U NA U Yes U No U NA
Wait time between applying
pressure/vacuum/water and
starting test
Test Start Time:
Initial Reading :
Test End Time:
Final Reading RF ):
Test Duration:
Change in Reading R, :
Pass/Fail Threshold or Criteria:
Test Result: U : t, . U >Er»ss U Pass. U I iil U mass U I+$0l'
Was sensor removed for testing? U Yes U No U NA UYes U No U NA U Yes UNo U NA U Yes U No U NA
Was sensor properly replaced and
verified functional after testin ?
U Yes U No U NA U Yes UNo U NA U Yes U No U NA U Yes U No U NA
COIf1ItlelttS — (include in on repairs madeprior to testing, andrecommendedjollow- y orfailed tests)
S4t nn t ,eft 04- J,Mt
If the entire depth of the UDC is not tested, specify how much was tested. If the answer to g= ofthe questions indicated with an
asterisk (s) is "NO" or "NA", the entire UDC must be tested. (See SWRCB LG -160)
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SW RCB, January 2002
S. FILL RISER CONTAINMENT SUMP TEST
Facility is Not Equieped With Fill Riser Containment Sumps
Fill Riser Containment Sumps are Present, but were Not Tested U
Test Method Developed By: U Sump Manufacturer U Industry Standard
U Other (Specify)
Test Method Used: U Pressure U Vacuum
U Other (Sped)
Test Equipment Used: Eqt
Son Fill SUMP # Fill Samp # Fill
S
Page -3— of
Professional Engineer
Hydrostatic
Resolution:
I®
Fill Sump#
Comments — (include information on repairs made prior to testing, and recommendedfollow- upforfailed tests)
Sump Depth:
Height from Tank Top to Top of
Highest Piping Penetration:
Height from Tank Top to Lowest
Electrical Penetration:
Condition ofsump prior to
testing:
Portion of Sump Tested
Sump Material:
Wait time between applying
pressure/vacuum/water and
starting test:
Test Start Time:
Initial Reading
Test End Time:
Final Readin R.F :
Test Duration:
Change in Reading R, :
Pass/Fail Threshold or Criteria:
Test Result: U U. I. U Pass U.I41 U Buss U Fall U P-mi. U Fail
is there a sensor in the ? U Yes U No U Yes U No U Yes U No U Yes U No
Does the sensor alarm when
either product or water is
detected?
U Yes U No U NA U Yes U No U NA U Yes U No U NA U Yes U No U NA
Was sensor removed for testing? U Yes U No U NA U Yes U No U NA U Yes U No U NA U Yes U No U NA
Was sensor properly replaced and
verified functional after testing?
U Yes U No U NA U Yes U No U NA U Yes U No U NA U Yes U No U NA
Comments — (include information on repairs made prior to testing, and recommendedfollow- upforfailed tests)
r
SWRCB, January 2002
9. SPILL/OVERFILL CONTAINMENT BOXES
Facility is Not Equipped With Spill/Overfill Containment Boxes U
Spill/Overfill Containment Boxes are Present, but were Not Tested U
i Test Method Developed By. U Spill Bucket Manufacturer (t9.industry Standard
U Other (Specify)
Test Method Used: U Pressure U Vacuum
U Other (Specify)
Test Equipment Used: P. .._si c Eauinmen
Bucket Diameter:
Spill Box # Spi1l Box #
Bucket Depth:
Wait time between applying
pressurelvacuum/water and
starting, test: 6-am I
Test Start Time:
Initial Reading (R,): tG
Test End Time: g;
Final Reading (RF): 8
Test Duration:
Change in Reading (RF -RO:
Pass/Fail Threshold or
Criteria:
Page ( 0 ofX
U Professional Engineer
Hydrostatic
Resolution:
Box # Spin Box #
Pass U Fall j 111%39 U Nail U Pass U Intl U Am U FAII
Comments — (include information on repairs made prior to testing; andrecommendedfollow -upforfailedtests)
MONITORING SYSTEM CERTIFICATION
For Use ByAll Jurisdictions Within the State ofCaliforniajAuthorityCited. Chapter 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, California Code ofRegulations
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 pgnel by the technician who performs the work. A copy of this form must be provided to the tank
system ownedoperator. The owner /operator must submit a copy of this form to the local agency regulating UST systems within 30
days oftest date.
A. General Information
Facility Name: KLrh rnwi t eYl ,m/ —e l^wap s Bldg. No.:
Site Address: MIS- 7%'44,r2!t 1 4VZ. City: LA &a =CA1ez1A1_1
Zip:
Facility Contact Person: Contact Phone No.:
Make/Model ofMonitoring System: Date of Testing/Servicing: IQ / R07
B. Inventory of Equipment Tested/Certified
Mfr+ the annmnriate hn " to InAnrata a irtr rm,1 -t t-M.A/.or 4t A.
Tanis ID: Tank ID:
FA In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model:
W Annular Space or Vault Sensor. Model: Id O AnnularSpace or Vault Sensor. Model:
AN Piping Sump/ Trench Sensor(s). Model: SLA_kke S'ek -for Piping Sump /Trench Sensor(s). Model:
Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model:
Mechanical line Leak Detector. Model: O Mechanical Line Leak Detector. Model:
0 Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Mode]:
Tank Overfill /High -Level Sensor. Model: O Tank Overfill /High -Level Sensor. Model:
O Others equipment type and model in Section E on Page 2). Other equipment and model in Section E on Page 2).
Tank ID: Tank ID•
O In -Tank Gauging Probe. Model: Cl In -Tank Gauging Probe, Model:
O Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model:
O Piping Sump /Trench Sensor(s). Model: O Piping Sump /Trench Sensor(s). Model:
Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model:
Mechanical Line Leak Detector. Model: O Mechanical Line Leak Detector. Model:
O Electronic Line Leak Detector. Model: O Electronic Line Leak Detector. Model:
Cl Tank Overfill / High -Level Sensor. Model: O Tank Overfill / High -Level Sensor. Model:
O Other (specify cquinent and model in Section E on PaLe 2). Other (sgejfy 59uip!nent!Xl?S and model in Section E on Pa 2).
Bispenser ID• &_& Dispenser ID:
Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model:
O Shear Valve(s). O Shear Valve(s).
Cl Dispen ser Containment Float(s) and Chain(s). Dispenser Containment Float(!2 and Chain(s).
Dispenser ID: Dispenser ID:
O Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model:
O Shear Valve(s). O Shear Valve(s).
Dispenser Containment Floats and Chain(s). O Dispenser Containment Float (s) and Chain s .
Dispenser ID• Dispenser ID:
Dispenser Containment Sensor(s). Model: O Dispenser Containment Sensor(s). Model:
O Shear Valve(s). O Shear Valve(s).
UDispenser Containment Floats and Chain(s). Dispenser Containment Floats 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 is accordance with the manufacturers'
guidelines. Attached to this Certification is information (e.g. facturers' checklists) necessary to verify that this information is
correct and a Plot Plan showing the layout of moaitorJngpmeut. For any equipment capable of generating such reports, I have also
attached a copy ofthe rt; (check ail that apply): W System set -up 19 Alarm history report
Technician Name (print): eQ u/. ZZi a.rg_ Signature:
Certification No.: ;2s212_ License. No.:
Testing Company Name: _ Ca/- VQ // Ae- 6u;em e,I1~ Phone No.: ( 66/ 32 % 93 ti/
Site Address: _ YJS- Y_' : kftf h f r S 'i 'A Date of Testing/Semvicing. AP_k p7
Page 1 of 3 0"1
Monitoring System Certification
D. Results of Testing/Servicing
Software Version Installed:
L`mnn4.ta fhP MUnmino rhpelrilct-
104 No* Is the audible alarm oral?
lib) Yes O No* Is the visual alarm rational?
Yes O No* Were all sensors visually inspected, functionally tested, and confirmed operational?
54 Yes No* Were all sensors installed at lowest point of secondary containment and positioned so that other equipment will
not interfere with their proper lion?
Yes D No* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modem)
CO N/A operational?
Yes O No* For 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? If yes: which sensors initiate
positive shut -down? (Check all that apply) 0 Sump/Trench Sensors; Dispenser Containment Sensors.
Did you confirm positive shut -down due to leaks Md sensor failure/disconnection? ® Yes; No.
O Yes O No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e. no
91 N/A 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?9b
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* O No Was liquid found inside any secondary containment systems designed as dry systems? (Check all that apply)
Product; Water. Ifyes, describe causes in Section E, below.
Yes 13 No* Was monitoring s stem set-up reviewed to ensure settings? Attach set u reports, ifapplicable1YesNo* 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: ne- Stcm4 sei- ?rgr dual r -eplaceeY: Tie rn,ts,Jh
gel kwo #Y- W_4-L cal/ v-C Wa.%1^ Seh rari' 1--2- aa4Z -G' Were I'L Q -1-arIIn k6k- h
T— "'v -fd oh ','y t Si'te 11,0,f p0 frf7'yP t'l, -k' Lam, S -eh rb & rf 1p have
yeti J42 alatrl" Sr'h /-7 20 6
Page 2 of 3 03/01
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F. 'In -Tank Gauging / SIR Equipment: ® Check this box if tank gauging is used only for inventory control.
O 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.
Vmmnlete the fnllnarimr rhorldide
Yes No* Has all input wiring been inspected for proper entry and termination, including testing for ground faults?
Yes O No* Were all tank gauging probes visually inspected for damage and residue buildup?
Yes No* Was accuracy of system product level readings tested?
13 Yes O No* Was accuracy ofsystem water level readings tested?
O Yes Cl No* Were all probes reinstalled properly?
Yes O No* Were all items on the equipment manufacturer's maintenance checklist completed?
In the Section $. below. describe how and when these deficiencies were or will he corrected.
G. Line Leak Detectors (LLD):
mmrlete the fnllnvinv rherkliat-
O Check this box ifLLDs are not installed
O Yes V No* For equipment start -up or annual equipment certification, was a leak simulated to verify LLD performance?
N/A Check all that apply) Simulated leak rate: O 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?
O Yes O No* Was the testing apparatus properly calibrated?
Yes No* For mechanical LLDs, does the LLD restrict product flow if it detects a leak?
O N/A
Yes No* For electronic LLDs, does the turbine automatically shut off ifthe LLD detects a leak?
go N/A
Yes O No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
0 N/A or disconnected?
Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system matfimctions
0 N/A or fails a test?
Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected?
N/A
O Yes I CO No* I 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: The L122d'la{,it^A/ 1Ihe etecterCac_&Znothe fnr,inot', 'lie
Yv IMP- veer 2 yM,*ht /'k ty the _ t UlZt& Mo Sln Tear OLA-e oy .S,00ki" A/
vAIlve.
Page 3 of 3 03/01