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HomeMy WebLinkAbout3698 MING AVENUE (5)oW SWRCB, January 2002 Page of Secondary Containment Testing Report Form Thisform is intendedfor use by contractors performingperiodic testing ofUSTsecondary containment systems. Use the appropriate pages ofthis form to report resultsfor all components tested The completedform, written test procedures, and printoutsfrom tests (ifapplicable), should beprovided to thefacility owner /operatorfor submittal to the local regulatory agency. 1. FACILITY INFORMATION Facility Name: SHELL STATION Date ofTesting: 2/21/12 Facility Address: 3698 MING AVENUE, BAKERSFIELD Facility Contact: I Phone: Date Local Agency Was Notified of Testing: 1 / H /12 Name of Local Agency Inspector (ifpresent during testing): 2. TESTING CONTRACTOR INFORMATION Company Name: Rich Environmental Pass Technician Conducting Test: RICH PHILLIPS Not Tested Credentials: X CSLB Licensed Contractor SWRCB Licensed Tank Tester License Type: C61/1)40 A HAZ License Number: 809850 Manufacturer Manufacturer Training Component(s) Date Training Expires INCON TS -STS 6/11/2012 X UDC #1 12 X 3. SUMMARY OF TEST RESULTS Component Pass Fail Not Tested Repairs Made Component Pass Fail Not Tested Repairs Made 87 ANNULAR X UDC #1 12 X 89 ANNULAR X UDC 43/4 X 91 ANNULAR X UDC 45/6 X DIESEL ANNULAR X UDC #7/8 X 87 SECONDARY X1 87 FILL SUMP X 89 SECONDARY X 89 FILL SUMP X 91 SECONDARY X 91 FILL SUMP X DIESEL SECONDARY X DIESEL FILL SUMP X 87 STP X 87 VAPOR BUCKET X 89 STP X 89 VAPOR BUCKET X 91 STP X 191 VAPOR BUCKET JXJ DIESEL STP X1 10 1 If hydrostatic testing was performed, describe what was done with the water after completion of tests: CERTIFICATION OF TECHNIC RESPONSIBLE FOR CONDUCTING THIS TESTING To the best ofmy knowledge, thefacts stated' document are accurate and in full compliance with legal requirements Technician's Signature: Date: 2/21/12 SWRCB, January 2002 4_ TANK ANNTFEAR TESTING Page T of If Test Method Developed By: 0 Tank Manufacturer X Industry Standard 0 Professional Engineer Other (Specify) Test Method Used: Pressure X Vacuum 0 Hydrostatic Other (Specify) Test Equipment Used: 4" DIAL GAUGE Equipment Resolution: Tank # 87 ANN Tank #89 AN Tank #91 ANN Tank #DSL ANN Is Tank Exempt From Testing ?' X Yes 0 No X Yes No X Yes No X Yes No Tank Capacity: Tank Material: Tank Manufacturer: Product Stored: Wait time between applying pressure /vacuum/water and starting test: 30MIN 30MIN 30MIN 30MIN Test Start Time: Initial Reading (Ri): Test End Time: Final Reading (RF): Test Duration: 60 MIN 60 MIN 60 MIN 60MIN Change in Reading (RF -R,): Pass /Fail Threshold or Criteria: Test Result: 0 Pass 0 Fail 0 Pass Fail 0 Pass 0 Fail Pass Fail Was sensor removed for testing? Yes No NA 0 Yes 0 No 0 NA 0 Yes 0 No 0NA Yes No NA Was sensor properly replaced and verified functional after testing? Yes C No NA 0 Yes No NA 0 Yes 11 No NA 0 Yes No NA Comments — (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) SITE HAS LIQUID FILLED ANNULARS 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)) SWRCB, January 2002 5. SECONDARY PIPE TESTING JIOVV Page 3 of Test Method Developed By: 0 Piping Manufacturer X Industry Standard Professional Engineer Other (Specify) Test Method Used: X Pressure 0 Vacuum Hydrostatic 0 Other (Spec) Test Equipment Used: 4" DIAL GAUGE Equipment Resolution: .5% Piping Material: Piping Run #87 SEC Piping Run #89 SEC Piping Run #91 SEC Piping Run #DSL SEC FIBERGLASS FIBERGLASS FIBERGLASS FIBERGLASS Piping Manufacturer: UNKNOWN UNKNOWN UNKNOWN UNKNOWN Piping Diameter: 2" 2" 2" 2" Length ofPiping Run: 80' 80' 80' 50' Product Stored: GASOLINE GASOLINE GASOLINE DIESEL Method and location of piping-run isolation: BOOT IN SUMP BOOT IN SUMP BOOT IN SUMP BOOT IN SUMP Wait time between applying pressure /vacuum /water and starting test: 30 MIN 30 MIN 30 MIN 30 MIN Test Start Time: 9:30 9:30 10:45 10:45 Initial Reading (R,): 5 5 5 5 Test End Time: 10:30 10:30 11:45 11:45 Final Reading (RF): 5 5 5 5 Test Duration: 60 MIN 60 MIN 60 MIN 60 MIN Change in Reading (RF -R,): 0 0 0 0 Pass/FaiI Threshold or Criteria: 0 0 0 0 Test Result: X Pass 0 Fail X Pass 0 Fail X Pass Fail X Pass 0 Fail Comments — (include information on repairs made prior to testing•, and recommendedfollow -upforfailed tests) SWRCB, January 2002 6. PIPING SUMP TESTING gc-j (0UV Page -f ofV , Test Method Developed By: Sump Manufacturer X Industry Standard Professional Engineer Other (Spec) Test Method Used: Pressure Vacuum X Hydrostatic Other (Spec) Test Equipment Used: INCON TS -STS Equipment Resolution. Sump #89 Sump #91 Sump #DSLSump #87rSumpameter. 39" 39" 39" 39" pth: 63" 63" 63" 63" Sump, aterial: FIBERGLASS FIBERGLASS FIBERGLASS FIBERGLASS Height from Tank Top to Top of Highest Piping Penetration: 12" 12" 11" 13" Height from Tank Top to Lowest Electrical Penetration: 19" 20" 19" 19" Condition of sump prior to testing: GOOD GOOD GOOD GOOD Portion of Sump Tested' 14" 14" 13" 15" Does turbine shut down when sump sensor detects liquid (both product and water)?* Yes No X NA Yes No X NA Yes No X NA Yes No X NA Turbine shutdown response time Is system pTogrammed for fail -safe shutdown? Yes No X NA Yes No X NA Yes No X NA Yes No X NA Was fail -safe verified to be operational?* Yes No X NA Yes No X NA Yes []No X NA Yes No XNA Wait time between applying pressure/vacuum/water and starting test: 30 MIN 30 MIN 30 MIN 30 MIN Test Start Time: 12:55 1:13 1:41 1:58 1:41 1:58 1:41 1:58 Initial Reading (PQ; 4.289 4.290 5.013 5.013 6.681 6.681 6.620 6.620 Test End Time: 1:10 1:28 1:57 2:13 1:57 2:13 1:57 2:13 Final Reading (RF): 4.290 4.290 5.013 5.013 6.681 6.681 6.620 6.620 Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN Change in Reading (RF -R,): 001 000 000 000 000 000 000 000 Pass/Fail Threshold or Criteria: 002 002 002 002 002 002 002 002 Test Result: X Pass Fail X Pass Fail X Pass Fail X Pass Fail Was sensor removed for testing? X Yes No NA X Yes ONO NA X Yes No NA X Yes No NA Was sensor properly replaced and verified functional after testin ? X Yes No NA X Yes ONO NA X Yes No NA X Yes No NA Comments - (include information on repairs made prior to testing, and recommendedfollow -upfor failed tests) If the entire depth ofthe sump is not tested, specify how much was tested. If the answer to any ofthe questions indicated with an asterisk(*) is "NO" or "NA ", the entire sump must be tested. (See SWRCB LG -160) SWRCB, January 2002 7. UNDER- DISPENSER CONTAINMENT fUDQ TESTING PageerZ of Test Method Developed By: UDC Manufacturer X Industry Standard Professional Engineer 0 Other (Specify) Test Method Used: Pressure 0 Vacuum X Hydrostatic Other (Specify) Test Equipment Used: INCON TS -STS Equipment Resolution: Im UDC #7/8 UDC Manufacturer. UDC #1/2 UDC #3/4 UDC #5/6 UNKNOWN UNKNOWN UNKNOWN UNKNOWN UDC Material: FIBERGLASS FIBERGLASS FIBERGLASS FIBERGLASS UDC Depth: 34" 34" 34" 34" Height from UDC Bottom to Top of Highest Piping Penetration: 13" IF 12" 12" Height from UDC Bottom to Lowest Electrical Penetration: 18" 22" 17" 14" Condition ofUDC prior to testing: GOOD GOOD GOOD GOOD Portion of UDC Tested 15" 18" 14" 14" Does turbine shut down when UDC sensor detects liquid (both product and water) ?* Yes 0 No X NA Yes []No X NA Yes No X NA 0 Yes No X NA Turbine shutdown response time Is system programmed for fail- safe shutdown ?* C Yes No X NA C Yes 0No XNA Yes 0 No XNA 0 Yes No XNA Was fail -safe verified to be operational?* Yes No X NA Yes No X NA 0 Yes No X NA 0 Yes 0No X NA Wait time between applying pressure/vacuum/water and starting test 30MIN 30MIN 30MIN 30MIN Test Start Time: 3:50 4:07 2:52 3:20 3:50 4:07 2:52 3:20 Initial Reading j): 6.334 6.334 5.746 5.745 4.312 4.312 6.454 6.454 Test End Time: 4:05 4:22 3:07 3:35 4:05 4:22 3:07 3:35 Final Reading F : 6.334 6.334 5.745 5.745 4.312 4.312 6.454 6.454 Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 1 15MIN Change in Reading (RF -R,): 000 000 001 000 000 000 000 1 -.000 Pass/Fail Threshold or Criteria: 002 002 002 002 002 002 002 002 Test Result: X Pass 0 Fail X Pass 0 Fail X Pass 0 Fail X Pass 0 Fail Was sensor removed for testing? X Yes No NA X Yes No DNA X Yes 0 No NA X Yes No NA Was sensor properly replaced and verified functional after testin . X Yes 0 No 0 NA X Yes C No 0 NA X Yes 0 No NA X Yes 0No NA Comments - (include information on repairs made prior to testing, and recommendedfollow -upforfailed tests) If the entire depth ofthe UDC is not tested, specify how much was tested. Ifthe answer to any ofthe questions indicated with an asterisk ( *) is "NO" or "NA ", the entire UDC must be tested. (See SWRCB LG -160) SWRCB, January 2002 8. FELL RISER CONTAINMENT SUMP TESTING LV;31ow . Page 6 ofik Facility is Not Equipped With Fill Riser Containment Sums 0 Fill Riser Containment Sumps are Present, but were Not Tested 0 Test Method Developed By: Sump Manufacturer X Industry Standard 0 Professional Engineer 0 Other (Spec) Test Method Used: 0 Pressure 0 Vacuum X Hydrostatic Other (Spec) Test Equipment Used: INCON TS -STS Equipment Resolution: Fill Sumn 987 Fill Sumo #89 1 Fill Sumo #91 1 Fill Sumn #DSL Sump Diameter. 39" 39" 39" 39" Sump Depth: 64" 64" 64" 64" Height from Tank Top to Top of Highest Piping Penetration: 13" IF) 12" 12" Height from Tank Top to Lowest Electrical Penetration: 18" IT, 18" 18" Condition of sump prior to testing: GOOD GOOD GUUD juuu Portion of Sump Tested 16" 13" 14" 14" Sump Material: FIBERGLASS FIBERGLASS FIBERGLASS FIBERGLASS Wait time between applying pressure /vacuum/water and starting test: 30MIN 30MIN 30MIN 30MIN Test Start Time: 12:55 1:13 12:55 1:13 12:55 1:13 12:06 12:31 Initial Reading (Rj): 3.317 3.317 4.512 4.513 2.960 2.961 6.557 6.557 Test End Time: 1:10 1:28 1:10 1:28 1:10 1:28 12:22 12:47 Final Reading F : 3.317 3.317 4.513 4.513 2.961 2.961 6.557 6.557 Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN 15MfN Change in Reading (RF -Rj): 000 000 001 000 001 1 -.000 000 -.000 Pass/Fail Threshold or Criteria: 002 002 002 002 002 002 002 -.002 Test Result; X Pass Fail X Pass Fail X Pass Fail X Pass Fail Is there a sensor in the sump? X Yes 0 No X Yes 0 No X Yes No X Yes No Does the sensor alarm when either product or water is detected? Yes No X NA 0 Yes 0 No . X NA Yes No X NA 0 Yes No X NA Was sensor removed for testing? Yes- No NA X Yes No NA X Yes No NA X Yes No NA Was sensor properly replaced and verified functional after testing? X X Yes 0 No 0 NA X Yes No NA X Yes 0 No NA X Yes 0 No NA Comments - (include information on repairs made prior to testing, andrecommendedfollow -upforfailed tests) SWRCB, January 2002 9. SPILL/OVERFILL CONTAINMENT BOXES dilvlr Page j of Facility is Not Equipped With Spill/Overfill Containment Boxes SpilllOverfill Containment Boxes are Present, but were Not Tested 0 Test Method Developed By: 0 Spill Bucket Manufacturer X Industry Standard 0 Professional Engineer Other (Spec) Test Method Used: 0 Pressure Vacuum X Hydrostatic 0 Other (Specify) Test Equipment Used: INCON TS -STS Equipment Resolution: Spill Box #87 VPR Spill Box #89 VPR Spill Box #91 VPR Spill Box # Bucket Diameter. 12" 12" 12" Bucket Depth: 16" 16" 16" Wait time between applying pressure /vacuum/water and starting test: 30M[N 30MIN 30M1N Test Start Time: 12:06 12:31 12:06 12:31 12:06 1 12:31 Initial Reading (R,): 6.425 6.425 6.978 6.978 7.420 7.420 Test End Time: 12:22 12:47 12:22 12:47 12:22 12:47 Final Reading (RF): 6.425 6.425 6.978 6.978 7.420 7.420 Test Duration: 15MIN 15MIN 15MIN 15MIN 15MIN 15MIN Change in Reading (RF -Rj): 000 000 000 000 000 000 Pass/Fail Threshold or Criteria: 002 002 002 002 002 002 Test Result: X Pass 0 Fail X Pass 0 Fail X Pass 0 Fail 0 Pass Fail COMMIAs — (include information on repairs made prior to testing, and recommendedfollow- upforfailed tests) SHELL 3698 MING ruE BAKERSFIELD 02/14,2012 12:22 PM SUMP LEAK TEST REPORT 87UPR TEST 3TARTEV- 12:06 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.4254 IN END TIME 12:22 PM END DATE 01/14/2012' END LEVEL 6.4252 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 8:! IPR TEST STARTED 1.06 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.9782 IN END TIME 12:[2 r19 END DATE 01/14/2012 END LEVEL 6.9780 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 91VPR TEST STARTED 12:06 PM TEST STARTED 01/14/2012BEGINLEVEL7.4209 IN END TIME 12:22 PM END DATE 01/14/2012 END LEVEL 7.4208 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED DSLF IL1 TEST STARTED 12:06 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.5577 IN END TIME 12:22 PM END DATE 01/14/2012 END LEVEL 6.5577 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED SHELL 3598 MINI, AVE BAKERSFIELD 2012 12:47 PM SUMP LEAK TEST REPORT 87UPR TEST STARTED 12:31 PM TEST STARTED Oi/14/2012 BEGIN LEVEL 6.4251 IN END TIME 12:47 Phi END DATE 01/14/2012 END LEVEL 6.4254 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 854UPR TEST STARTED TEST STARTED BEGIN LEVEL END TIME END DATE END LEVEL LEAK THRESHOI TEST RESULT 12:31 PM 01/14/2012 6.9781 IN 12:47 PM 01/14/2012 6.9781 IN D 0.002 IN PASSED 91UPR TEST STARTED TEST STARTED BEGIN LEVEL END TIME END DATE END LEVEL LEAK THRESHOI TEST RESULT 12:31 PM 01/14/2012 7.4207 IN 12:47 Ph 01/142012 7.4207 IN D 0.002 IN PASSED DSLFILL TEST STARTED 12:31 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.5575 IN END TIME 12:47 PM END DATE 01/14/2012 END LEVEL 6.5577 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED HELL` 3K MIND AVE 9Ar3KERSFIELO,, 441+2012 i :10 Ph SUMP LEAK TEST REPORT 87FILS TEST STEWED 12:55 Rl TEST STARTED 01/14/2012 BEGIN LEVEL 3.3176 IN END TIME 1:10 Phi END DATE 01/14/2012 QND LEVEL 3.3178 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 89FILS TEST STARTED 12:55 PMTESTSTARTED01/14,1-2012 BEGIN LEVEL 4.5124 INENDTIME1:10 PM END DATE 01/14/2012 END LEVEL 4.5134 IN LEAK THRESHOLD 6.002 IN TEST RESULT PASSED 91FILS TEST STARTED 12:55 PM TEST STARTED 01/14/2012 BEGIN LEVEL 2.9609 IN END TIME 1:10 P9 END DATE 01;'14/2012ENDLEVEL2.9616 IN LEAK THRESHOLD 0.002 INTESTRESULTPASSED 87STP TEST STARTED 12:55 PMTESTSTARTED01/14/2012 BEGIN LEVEL 4.2898 IN END TIME 1 :10 PMENDDATE01/14/2012 END LEVEL 4.2900 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 3698jHI AVE BAKERSFIELD 6rA4/2012 1:29 PM SUMP LEAK TEST REPORT 87FILS TEST STARTED 1:13 PMTESTSTARTED01/14/2012BEGINLEVEL3.3176 INENDTIME1:28 PPiENDDATE01/14/2012ENDLEOELs3.3176 INLEAKTHRESHOLD0.002 INTESTRESULTPASSED 89FILS TEST STARTED 1:13 PMTESTSTARTED01/14/2012BEGINLEVEL4.5135 INENDTIME1 :28 PMENDDATE01/14/2012ENDLEVEL4.5136 INLEAK. THRESHOLD 0.002 INTESTRESULTPASSED 91FILS TEST STARTED 1:13 PMTESTSTARTED01/14/2012BEGINLEVEL2.9619 INENDTIME1 :28 PMENDDATE01/14/2012ENDLEVELZ.9621 INLEAKTHREL LD 0.002 INTESTRESULPASSED 87STP TEST STARTED 1:13 PMTESTSTARTED01/14/2012BEGINLEVEL4.2902 INENDTIME END DATE 1 :28 PM 01/14/2012ENDLEVEL4.2904 INLEAKTHRESHOLD0.002 INTESTRESULTPASSED SHELL ' 3698 MING AUE' BAKERSFIELD l`vg4/2012 1:57 PM SUMP LEAK TEST REPORT 89STP TEST STARTED 1:41 PM TEST STARTED 01/14/2012 BEGIN LEVEL 5.0135 IN END TIME 1:57 PM END DATE 01/14/2012 END LEUEL 5.0134 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED 91STP TEST STARTED 1:41 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.6816 IN END TIME 1:57 Ph END DATE 01/14/2012 END LEVEL 6.6815 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED DSLSTP TEST STARTED 1:41 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.6205 IN END TIME 1:57 PM END DATE 01/14/2012 END LEVEL 6.6204 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED SHELL 3698 MING AUE BAKERSFIELD a,%P /2012 3:07 PM SUMP LEAK TEST REPORT DSI7 -8 TEST STARTED TEST STARTED BEGIN LEVEL END TIME END DATE END LEVEL LEAK THRESHO TEST RESULT 2:52 PM 01/14/2012 6.4544 IN 3:07 Phi 01/14/2012 6.4546 IN 0. 002 PASSED DSI3 -4 TEST STARTED TEST STARTED BEGIN LEVEL END TIME END DATE END LEVEL LEAK THREW TEST RESULT 2-52 .Pt) 01/14/2012 5.7464 IN 3 :0? PM 01/14/2012 5.7457 IN 1LD O' PASSED HELL 3698 MING AVE BfiKERSFIELO Wy 4 /2012. 2:13 PM SUMP LEAK TEST riEPORT 89STP TEST STARTED 1 :58 PM TEST STARTED 05/11/4012BEGINLEVEL2:13 PMENDTIME01/14/2012ENDDATE END LEVEL 5.0136" IN LEAK EST RESULT 0' PASSED 91STP TEST STARTED 1:56 PM TEST STARTED 01/14/''012 BEGIN LEVEL 6.6816 IN END TIME 2:13 PM END DATE 01/14/2012 END LEVEL 6.6819 IN LEAK THRESHOLD 0.002 IDTESTRESULT DSLSTP TEST STARTED 1 :58 PM TEST STARTED 06/620INBEGINLEUEL2:13 PMENDTIME END DATE 01/14/2012 6.6208 INENDLEVEL LEAK THRESHOLD 0• PASSED 0214 TEST RESULT SHELL 3698 MING AVE BAKERSFIELD 014A/2012 3135 PM SUMP LEAK TEST REPORT DSI7 -6 TEST STARTED 3:20 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.4544 IN END TIME 3:35 PM END DATE 01/14/2012 END LEVEL 6.4545 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED DSI3 -4 TEST STARTED 3:20 PM TEST STARTED 01/14/2012 BEGIN LEVEL 5.7458 IN END TIME 3:35 PM END DATE 01/14/2012 END LEVEL 5.7457 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED SHELL 3698 MING AVE BAKERSFI ELD 2012 4:05 Ki VSUMP LEAK TEST REPORT DSI5 -6 TEST STARTED ::50 PM TEST STARTED 01/14/2012 BEGIN LEVEL 4.3122 IN END TIME 4:05 PM END DATE 01/14/2012 END LEUEL 4.3122 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED DS 11-2 TEST STARTED 3:50 PM TEST STARTED 01 /14/2012 BEGIN LEVEL 6.334: IN END TIME 4:05 P9 END DATE 01/14/2012 END LEVEL 6.3342 IN LEAK THRESHOLD 0.002 IN TEST RESULT ?'ASSED SHELL 3698 MING AVE BAKERSF I E1 D 2012 4:22 Pal SUMP LEAK TEST REPORT DSI5 -6 TEST STARTED 4:07 PM TEST STARTED 01/14/2012 BEGIN LEVEL 4.3122 IN END TIME 4:22 PM END DATE 01/14/2012 END LEVEL 4.3122 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED N1 1-2 TEST STARTED 4:07 PM TEST STARTED 01/14/2012 BEGIN LEVEL 6.3344 IN END TIME 4:22 Rl END DATE 01/14/2012 END LEVEL 6.349 IN LEAK THRESHOLD 0.002 IN TEST RESULT PASSED E SB989 TESTING FAILURE REPORT SITE NAME: .S fiii-L TA J Jol DATE: i/y /_ _ ADDRESS: -70f TECHNICIAN: RICH PHILLIPS r VTTV• /'lh -) Irl,tZn, GA 4ZMT*JATTTRF.- THE FOLLOWING COMPONENTS WERE REPLACED/REPAIRED TO COMPLETE TESTING. REPAIRS: kO)" i LABOR: Lofi- llbl" PARTS INSTALLED: NAME: TITLE SIGNATURE: THE ABOVE NAMED PERSON TAKES FULL RESPONSIBILITY 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.