HomeMy WebLinkAbout2601 WHITE LANE (5)Pzs s
MONITORING SYSTEM CERTIFICATION
to
For Use By All Jurisdictions Within the State ofCalifornia
Authority Cited: 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_renort must be prenaMd for each
monitoring sySem 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 ofthis fort to the local agency regulating UST systems within 30 days oftest date.
A. General Information
Facility Name: HARRY'S MARKET #2 Bldg. No.:
Site Address: 2601 WHITE LN City: BAKERSFIELD Zip:
Facility Contact Person: YOGI Contact Phone No.: ( )
Make /Model ofMonitoring System: TLS 350 Date ofTesting/Servicing: 11/17/2011
B. Inventory of Equipment Tested/Certified
Check the annronriate boxes to indicate snecifle eauipment insnected/serviced:
Tank ID: UNL871SPLIT Tank ID: PREM911SPLIT
In -Tank Gauging Probe. Model: MAG In -Tank Gauging Probe. Model: MAG
Annular Space or Vault Sensor. Model: 4201SPLIT Annular Space or Vault Sensor. Model: 420 /SPLIT
Piping Sump / Trench Sensor(s). Model: 208 Piping Sump/ Trench Sensor(s). Model: 208
Fill Sump Sensor(s). Model: 208 Fill Sump Sensor(s). Model: 208
Mechanical Line Leak Detector. Model: RED JACKET Mechanical Line Leak Detector. Model: RED JACKET
Electronic Line Leak Detector. Model: Electronic Line leak Detector. Model:
Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model:
Other (specify equipment type and model in Section E on Page 2). Other (specify equipment type and model in Section E on Page 2).
Tank ID: Tank ID:
In -Tank Gauging Probe. Model: In -Tank Gauging Probe. Model:
Annular Space or Vault Sensor. Model: Annular Space or Vault Sensor. Model:
Piping Sump / Trench Seasor(s). Model: Piping Sump / Trench Sensor(s). Model:
0 Fill Sump Sensor(s). Model: Fill Sump Sensor(s). Model:
Mechanical Line Leak Detector. Model: Mechanical Line Leak Detector. Model:
Electronic Line Leak Detector. Model: Electronic Line Leak Detector. Model:
Tank Overfill / High -Level Sensor. Model: Tank Overfill / High -Level Sensor. Model:
Other (specify equipment type and model in Section E on Page 2). Other (specify equipment type and model in Section E on Page 2).
Dispenser ID: 1 -2 Dispenser ID: 3-4
Dispenser Containment Sensor(s), Model: 208 Dispenser Containment Sensor(s). Model: 208
Shear Valve(s). Shear Valve(s).
Dispenser Containment Floats) and Chain(s). Dispenser Containment Float(s) and Chain(s).
Dispenser ID: 6.6 Dispenser ID: 7-8
DispenserContainment Sensor(s). Model: 208 Dispenser Containment Sensor(s). Model: 208
Shear Valve(s). Shear Valve(s).
Dispenser Containment Float(s) and Chain(s). Dispenser Containment Float(s) and Chain(s).
Dispenser ID: Dispenser ID:
Dispenser Containment Sensor(s). Model: Dispenser Containment Sensor(s). Model:
Shear Valve(s). Shear Valve(s).
Dispenser Containment Float(s) and Chain(s). Dispenser Containment Ftoat(s) and Chain(s).
Ifthe 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 inspectediserviced 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 ofgenerating such reports, I have also
attached a copy of the report; (check all that apply): ® System set -up ® Alarm history report
Technician Name (print): RICHARD MASON Signature: f.
Certification No.: 836880 / 5297857 -UT License. No.: —Cel D40 809850
Testing Company Name: RICH ENVIRONMENTAL Phone No.: (661) 392 -8687
Testing Company Address: 5643 BROOKS CT. BAKERSFIELD, CA 93308 Date of Testing/Servicing: 11117/2011
Page 1 of 5
UN -036 —114 www.unidoes.org Rev. 01117/08
Monitoring System Certification
1 D. Results of Testing/Servicing
Software Version Installed
Complete the following checklist:
44a% r
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* If alarms are relayed to a remote monitoring station, is all communications equipment (e.g., modem)
N/A operational?
Yes 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) ® Sump/Trench Sensors; ® Dispenser Containment Sensors.
Did you confirm positive shut -down due to leaks and sensor failure /disconnection? 0 Yes; No.
Yes No* For tank systems that utilize the monitoring system as the primary tank overfill warning device (i.e., no
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? %
Yes* No Was any monitoring equipment replaced? Ifyes, 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. Ifyes, 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 1 No* I 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:
Page 2 of 5
UN -036 — 2/4 www.unidomorg Rev. 01/17108
Monitoring System Certification
F. In -Tank Gauging / SIR Equipment: Check this box iftank 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?
13 Yes No* Were all tank gauging probes visually inspected for damage and residue buildup?
Yes No* Was accuracy ofsystem product level readings tested?
Yes No* Was accuracy of system water level readings tested?
Yes No* Were all probes reinstalled properly?
Yes 1 No* Were all items on the equipment manufacturer's maintenance checklist completed?
In Section H, below, describe how and when these deficiencies were or will be corrected.
G. Line Leak Detectors (LLD):
Complete the following checklist:
Check this box ifLLDs are not installed.
Yes 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; ® 3 g.p.h.; 0.1 g p.h ; [10.2 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* For mechanical LLDs, does the LLD restrict product flow ifit detects a leak?
N/A
Yes No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a Ieak?
N/A
Yes No* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled
N/A or disconnected?
Yes No* For electronic LLDs, does the turbine automatically shut off if any portion ofthe monitoring system malfunctions
N/A or fails a test?
Yes No* For electronic LLDs, have all accessible wiring connections been visually inspected?
N/A
Yes No* Were all items on the equipment manufacturer's maintenance checklist completed?
In Section H, below, describe how and when these deficiencies were or will be corrected.
H. Comments:
UN-M — 3/4
Page 3 of 5
www.unidocs.org Rev. 01/17/08
Monitoring System Certification Form: Addendum for Vacuum/Pressure Interstitial Sensors ' ` (all
I. Results of Vacuum/Pressure Monitoring Equipment Testing
This page should be used to document testing and servicing of vacuum and pressure interstitial sensors. A copy of
this form must be included with the Monitoring System Certification Form, which must be provided to the tank
system owner /operator. The owner /operator must submit a copy of the Monitoring System Certification Form to the
local agency regulating UST systems within 30 days oftest date.
Manufacturer: NONE Model: System Type: Pressure; ® Vacuum
Sensor ID
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result-. Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Components) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor.
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
Component(s) Monitored by this Sensor:
Sensor Functionality Test Result: Pass; Fail Interstitial Communication Test Result: Pass; Fail
How was interstitial communication verified?
Leak Introduced at Far End of Interstitial Space;' Gauge; Visual Inspection; Other (Describe in Sec. J, below)
Was vacuum/pressure restored to operating levels in all interstitial spaces? Yes No (Ifno, describe in Sec. J, below)
J. Comments: NONE OF THESE SENSORS ARE PRESENT AT THIS SITE.
Page 4 of 5
Ifthe sensor successfully detects a simulated vacuum/pressure leak introduced in the interstitial space at the furthest point from thesensor, vacuum/pressure has been demonstrated to be communicating throughout the interstice.
UN -036A - 1/1 www.unidocs.org Rev. 01/26/06
Moniwring System Ca fication
UST Monitoring; Site
Site Address:
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i
L. J: -------
r - - - - - - w - _ - r - . -_ _ _ - - _ L _ _ . _ - . - . . _ - • r -
If you already have a diagram that shows all required information, you may include it, rather than this page, with yourMonitoringSystemCerti$c idon. On your site plan, show the general layout oftanks and piping. Clearly idetr* locations ofthe following equipment, if installed: monitoring systft control panels; sensors monitoring tank annularspaces, sumps, dispenserpans, Viill containers, or other secondary couiainment areas; mechanical or electronic line leak
detectors; and ih-tank liquid level probes (ifused for leak detection). Iathe space provided, note the date this Site Planwasprepared.
Page 57 of C—
05100
44W.-S
SWRCB, January 2006%
Spill Bucket Testing Report Form
This form is intendedfor use by contractors performing annual testing of UST spill containment structures. The completedform and
printoutsfrom tests (rfapplicable), should beprovided to thefacility owner /operatorfor submittal to the local regulatory agency.
1. FACILITY INFORMATION
Facility Name: HARRY'S MARKET #2 Date of Testing: 11/17/11
Facility Address: 2601 WHITE LANE, BAKERSFIELD
Facility Contact: YOGI Phone.
Date Local Agency Was Notified of Testing:
Name of Local Agency Inspector (tfpresent during testing): ERNIE MADENA
2. TESTING CONTRACTOR INFORMATION
Company Name: RICH ENVIRONMENTAL
Technician Conducting Test: RICHARD MASON
Credentials': 0 CSLB Contractor X ]CC Service Tech. 0 SWRCB Tank Tester 0 Other (Spec)
License Number(s): 5297857 -UT
3. SPILL BUCKET TESTING INFORMATION
TestMethod Used: XHydrostatic d Vacuum Other
Test Equipment Used: VISUAL I Equipment Resolution: 0
Identify Spill Bucket (By Tank 1 REG 87 -FILL 2 PREM 91 -FILL 3 4
Number, StoredProduct, etc.
Bucket Installation Type: 0 Direct Bury 0 Direct Bury 0 Direct Bury 0 Direct Bury
Bucket Depth:
X Contained in Sump X Contained in Sump Contained in Sump 0 Contained in Sum
Bucket Diameter. i2" 12"
Bucket Depth: 14" 14"
Wait time between applying
vacuum/water and start oftest: 30 MIN 30 MIN
Test Start Time (TO: 9:OOAM 9:OOAM
Initial Reading (Rj): 9" 9"
Test End Time (TF): 10:OOAM 10:00AM
Final Reading (RF): 9" 9"
Test Duration (Tr. — Tj): 1 -HOUR 1 -HOUR
Change in Reading (RF - Rj): 0 0
Pass/Fail Threshold or
Criteria 0.00 0.00
Test Result: X Pass Fail X Pass Fall Pass Fail 0 Pass 0 Fail
Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests)
CERTIFICATION OF TECHNICIAN RESPONSIBLE FOR CONDUCTING THIS TESTING
I hereby certify that all Cite information contained in this report is true, accurate, and infull compliance with legal requirements.
Technician's Signature: — Date: 11 /17 /11
State laws and regulations do not currently require testing to be performed by a qualified contractor. However, local requirements
may be more stringent.
I
RICH ENVIRONMENTAL
5643 BROOKS CT. BAKERSFIELD, CA. 93308
OFFICE (661)392 -8687 FAX (661)392 -0621
PRODUCT LINE LEAK DETECTOR TEST
WORK SHEET
W /0#:
FACILITY NAME: HARRY'S MARKET #2
FACILITY ADDRESS: 2601 WHITE LN, BAKERSFIELD
PRODUCT LINE TYPE: PRESSURE
PRODUCT LEAK DETECTOR TYPE TEST TRIP PASS
BELOW P.S.I. OR
SERIAL NUMBER 3 G.P.H. FAIL
UNL87 L/D TYPE: RED JACKET
YES 10 PASS
SERIAL # MECHANICAL
PREM91 L/D TYPE: RED JACKET
YES 10 PASS
SERIAL # MECHANICAL
L/D TYPE:- PASS
YES
SERIAL # - FAIL
L/D TYPE: PASS
YES
SERIAL # FA1L
I CERTIFY THE ABOVE TESTS WERE CONDUCTED ON THIS DATE ACCORDING TO RED
JACKET PUMPS FIELD TEST APPARATUS TESTING PROCEDURE AND LIMITATIONS.
THE MECHANICAL LEAK DETECTOR TEST PASS / FAIL IS DETERMINED BY USING A
LOW FLOW THRESHOLD TRIP RATE OF 3 GALLONS PER HOUR OR LESS AT 10 P.S.I. I
ACKNOWLEDGE THAT ALL DATA COLLECTED IS TRUE AND CORRECT TO THE BEST
OF MY KNOWLEDGE.
TECHNICIAN: RICHARD MASON
SIGNATURE: DATE: I1 /17/11
q4zs
r
T 2:UNLEADED IN -TANK SETUP SYSTEM SETUP
PRODUCT CODE 1
THERMAL COEFF :.000700 NOV 16. 2011 8:59 Pt
TANK DIAMETER 114.00 T 1:PREMTANKPROFILE1PTPRODUCTCODE 2FULLVOL12000THERMALCOEFF :.000700 SYSTEM UNITSTANKDIAMETER114.00 U.S.
FLOAT SIZE: 4.0 IN. TANK PROFILE 1 PT
FULL VOL 8000 SYSTEM LANGUAGE
ENGLIENGLISH
ILIMIT-' HHIIGHRWATER 2.5 FLOAT SIZE: 4.0 IN. MON D YYYY HH:MMFSS
MAX OR LABEL VOL: 12000
OVERFILL LIMIT 90i WATER WARNING 2.0 GAS-N-00
2601WHITE LN
10800 HIGH WATER LIMIT: 2.5 BACKERSFIELD,CA
HIGH PRODUCT 89% MAX OR LABEL VOL: 8000 1-661- 833 -8553
10680
DELIVERY LIMIT 10% OVERFILL LIMIT 9
7200 SHIFT TIME 1 : DISABL
1200 HIGH PRODUCT gg% SHIFT TIME 2 : DISABLSHIFT
LOW PRODUCT 1200 7120
DELIVERY LIMIT : 89: SHIFT TIME 4 : DISABL
LEAK ALARM LIMIT: 99 640SUDDENLOSSLIMIT: 99 TANK PER TST NEEDED W
TANK TILT 0.00
PROBE OFFSET 0.00 LOW PRODUCT 500 DISABLED
TANK ANN TST NEEDED WLEAKALARMLIMIT: 99 DISABLEDSUDDENLOSSLIMIT: 99
SIPHON MANIFOLDED TANKS TANK TILT 0.00
PROBE OFFSET 0.00 LINE RE- ENABLE METHOD
TO: NONE PASS LINE TEST
LINE MANIFOLDED TANKS
TO' NONE SIPHON MANIFOLDED TANKS LINE PER TST NEEDED Wi
LEAK MIN PERIODIC: 0:
T4. NONE
LINE MANIFOLDED TANKS LINELINE ANN TST NEEDED WIDISABLED
0 TO: NONE
PRINT TC VOLUMES
LEAK MIN ANNUAL : 0% LEAK MIN PERIODIC: 0r/. ENABLED
0 0 TEMP COMPENSATION
PERIODIC TEST TYPE LEAK MIN ANNUAL 0•i VALUE (DEG F ): 60.0STICKHEIGHTOFFSET
STANDARD 0 DISABLED
DAYLIGHT SAVING TIME
ANNUAL TEST FAIL PERIODIC TEST TYPE DISABLED
ALARM DISABLED STANDARD
PERIODIC TEST FAIL
ALARM DISABLED ANNUAL TEST FAIL SYSTEM SECURITYALARMDISABLEDCODE : 000000
GROSS TEST FAIL
ALARM DISABLED PERIODIC TEST FAIL CUSTOM ALARM LABELSALARMDISABLEDDISABLED
ANN TEST AVERAGING: OFF GROSS TEST FAILPERTESTAVERAGING: OFF ALARM DISABLED
TANK TEST NOTIFY: OFF ANN TEST AVERAGING: OFF
TNK TST SIPHON BREAK:OFF PER TEST AVERAGING: OFF
DELIVERY DELAY 1 MIN TANK TEST NOTIFY: OFF
PUMP THRESHOLD : 10.00% TNK TST SIPHON BREAK:OFF
DELIVERY DELAY 1 MIN
PUMP THRESHOLD : 10.ON
ALARM HISTORY REPORT
SENSOR ALARM - - - --
L 1 :91TRUBINE
STP SUMP
SENSOR OUT ALARM
NOV 16, 2011 10:05 PM
FUEL ALARM
NOV 16, 2011 9:49 PM
FUEL ALARM
OCT 29, 2010 12:56 PM
ALARM HISTORY REPORT
SENSOR ALARM - - - --
L 2:91FILL
PIPING SUMP
SENSOR OUT ALARM
NOV 16, 2011 10:05 PM
FUEL ALARM
NOV 16, 2011 9:50 PM
FUEL ALARM
OCT 29, 2010 4:26 PM
ALARM
HISTORY
REPORT -
SENSOR ALAR11
SUMPU
BT '
NE
iB
tEO 6 0
2011 01 Og Prl
FUEL ALA2l 9:51 PM
NOV 16
DUEL ALARM . W7 1>14
pyp,RM
HISTORY
REPORT
SENOR ALARM - -
a:g? FILL
PIP1
SUMP
OUT '
st4BO 6. 2011 10:05
KOV
16,
1p
0 9:52
wv
F 22p10 4: t9 PM
REPORT
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wq 16,
2011 9.57 PM
v11EL ALA
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10 3 :02 PM
RECONCILIATION SETUP
AUTOMATIC DAILY CLOSING
TIME: 2:00 AM
PERIODIC RECONCILIATION
MODE: MONTHLY
TEMP COMPENSATION
STANDARD
BUS SLOT FUEL -METER TANK
TANK MAP EMPTY
SOFTWARE REVISION LEVEL
VERSION 123.02
SOFTWARE# 346123 -100 -C
CREATED - 02.11.25.15.17
NO SOFTWARE MODULE
SYSTEM FEATURES:
PERIODIC IN -TANK TESTS
ANNUAL IN -TANK TESTS
OUTPUT RELAY SETUP
R 1:UNLEADED SHUT -DOWN
TYPE:
STANDARD
NORMALLY CLOSED
LIQUID SENSOR ALMS
ALL :FUEL ALARM
ALL :SENSOR OUT ALARM
F. 2:PREM SHUT -DOWN
TYPE:
STANDARD
NORMALLY CLOSED
LIQUID SENSOR ALMS
ALL:FUEL ALARM
ALL:SENSOR OUT ALARM
LEAK TEST METHOD
TEST ANNUALLY: ALL TANK.
JAN WEEK 1 MON
START TIME : DISABLED
TEST RATE :0.20 GAL /HR
DURATION : 2 HOURS
TST EARLY STOP:DISABLED
LEAK TEST REPORT FORMAT
NORMAL
LIQUID SENSOR SETUP
L 1:91TRUBINE
TRI -STATE (SINGLE FLOAT)
CATEGORY : STP SUMP
L 2:91FILL
TRI -STATE (SINGLE FLOAT)
CATEGORY : PIPING SUMP
L 3:87TRUBINE
TRI -STATE (SINGLE FLOAT)
CATEGORY : STP SUMP
L 4:87 FILL
TRI -STATE (SINGLE FLOAT)
CATEGORY : PIPING SUMP
L 5:DISP 1x2
TRI -STATE (SINGLE FLOAT)
CATEGORY : DISPENSER PAN
L 6:DISP 3 *4
TRI -STATE (SINGLE FLOAT)
CATEGORY : DISPENSER PAN
L 7:DISP 5 *6
TRI -STATE (SINGLE FLOAT)
CATEGORY : DISPENSER PAN
L G:DISP 7x8
TRI -STATE (SINGLE FLOAT)
CATEGORY : DISPENSER PAN
L 9:ANNULAR
TRI -STATE (SINGLE FLOAT)
CATEGORY : ANNULAR SPACE
ALARM HISTORY REPORT
SENSOR ALARM - - - --
L 9:ANNULAR
ANNULAR SPACE
SENOR OUT ALARM
NOV 16. 2011 10:05 PM
FUEL ALARM
NOV 15. 2011 9:53 PM
FUEL ALARM
OCT 29, 2010 1:02 PM
COMMUNICATIONS SETUP
PORT SETTINGS:
NONE FOUND
RS -232 END OF MESSAGE
DISABLED
ALARM HISTORY REPORT
SENSOR ALARM - -- —
L 6:DISP 3 *4
DISPENSER FAN
SENSOR OUT ALARM
NOV 16. 2011 11:05 PM
FUEL ALARM
NOV 16. 2011 9:55 PM
FUEL ALARM
OCT 29. 2010 5:35 PM
ALARM HISTORY REPORT
SENSOR ALARM - - - -- L+7:DISP 5 *6
DISPENSER PAN
SENSOR OUT ALARMNOV16, 2011 10:05 PM
FUEL ALARM
NOV 16. 2011 9:59 PM
FUEL ALARM
OCT 29, 2010 1:06 PM
ARM HISTORY REPORT
SENSOR ALWA --
B :T11SP 7 *6A1gpEPiSERPAN
SENSOR OUT ALARM
NOV 16. 2011 10 05 PM
FUEL ALARM
NOV i 6. 2011 10:03 Pto4
FuEL ALARM
OM 29, 2010 4:23 PM
qf(o28 /
MONITOR CERT. FAILURE REPORT
SITE NAME : CT LkC' DATE :
ADDRESS: 3--W) ( W kTf- TECHNICIAN: •
CITY: ( K c k-D SIGNATURE : I
THE FOLLOWING COMPONENTS WERE REPLACEDMEPAhtED TO COMPLETE
TESTING.
REPAIRS: I\J Q N
LABOR: 6
PARTS INTALLED :
NAME : TITLE:
SIGNATURE:
THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILTTY OF NOTIFYING
THE APPROPRIATE PARTY TO HAVE CORRECTIVE ACTION TAKEN TO REPAIR
THE ABOVE LISTED PROBLEMS AND NOTIFYING RICH ENVIRONMANTAL FOR
ANY NEEDED RETESTING. THIS ALSO RELEASES RICH ENVIRONMENTAL OF
ANY FINES OR PENALTIES OCCURING FROM NON - COMPLIANCE.
A COPY OF THIS DOCUMENT HAS BEEN LEFT ON -SITE FOR YOUR
CONVIENENCE.