HomeMy WebLinkAboutUST-MONI-SYSTEM REP. 10/6/2004
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MONITORING SYSTEM CERTIFICATION
For Use By All Jul'isdictions WiThÏn the Stale of California
.-iIIfhoril}' Cired: ChLlpfer 6.7, Heaùh and Sajèry Code,' ChewIer 16, Division 3, Title 23, California Code ojRegu/miol1s
This rì:wm mllS¡ be used w docwnent testing and servicing of monitoring eqLdpment. A separate certification or report l1'\ust be I?rel?~\I"~d
['or èil..:h moniwring system control panel by the œclulician who p¢rforms the work. A copy of this form must be provided to the tank
SYSkll1 owner/operator. The owner/operator musc submit a copy of this form to the local agency regulating UST systems within 30
Liô).::; ()f [ö[ dmt'.
A. Gcilërallnformation
FùcllilY Name: .:so .( 1J¡ù ~'S A«.c.o
,
SÜc' .-'eddress: _~~ ßUcÆl OCÄ.1fA)S 13 1..11 ()
Fùc iliry Cùmacr Person:
M'iLè.l\1ûdd of Monitoring System: ~O N AA.) )( 'ï c., ~
Bldg. No.:
City: ,BIJ.~-¡::¡£In Zip: ______....
Contact Phone No,: ( ) ___.___..
Date of Testing/Servicing: -.1!2J 0" / ~":l_
B. lnVCllWfY of Equipment Tested/Certified
Ç,I~':(I; tÌir _"2£rü ri¡¡re boxes [0 iodic¡ rc s ccitic e ui OWl[ ins Jeeted/serviced:
if 'L\ II!. iD: --.....Lt..AJJ...... - 9'~ .., Ì\1. tÂ.<> ~
¡Iii 0 11l-Lmk Q<lllging Probe, Model:
¡'! ï!Í.. ,-..\.nnular Spacè or VaulI Sensor. Model:
I 0 Pipwg Swnp i Trench SenSOf(s). Model:
o Jill Sump Sensor(s). Model:
I 0 Î\kdl<wiL\1I Line Leak Detector. Modèl:
I 0 LkL'cJ'Onil.. Line Leak DètecLor. Madej:
o Lml;: Ovcr!1111 High-Level Sensor. Model: .
C;L LJfhc'r (sèL'iÌ\' è lJi l1lèlJr r' e and model in SecÖon E on Pae 2 .
T¡¡nk 1D: l. 1.) &....- ~ ~ - S J, eJ1..c.) íi
o )ll-l'aJlK Gauging Probe. Model:
f1( _-\JH\ular Spacè or Vaulr Sensor. ModeJ:
o Piping Sump I Trench Sensùr(s). Model:
o Fj1J Sump SenSOf(s). ModeJ:
o l\l.:ch,wi(;al Line Leak DerecIOr. Model:
CJ l:kcIrùlÙc Line Leak DeIècIor. Model:
OLmK Ov tr.t1 II I High-Level Sensor. Model:
OUrlkr_~~p'èèi!\ è( ui fi1ènr IV e and model in Section E on Pae 2 .
Dis[Jtllser lD:
o DispêllSèf Comainmem Sensor(s). Mpdel;
CJ Sltear Valvels). :
I
._9 Dj~~QL~11Sl'f çonrainmem Float s) and C!Ja.in(s).
OiS!H~JlSër iD:
I
o Di~pèl1Sèr Conrainmcm Sensor(s). Mpdel:
:1 0 She;,¡r V,¡J\.e(s),
II 0 D!~ )èIlSèr Comainmem Floa[(s
Dispenser iD:
I 0 ~. ~ () ~'1 d I
I . Dbpèn~èr Connunmef\t :Sensor s. LV 0 e :
i Ü ~lle:U" Va.1\'èls).
I OD1~ èJls.:r ~ùmÙ11lmènr Flam s and Chain(s).
"lî rl1è Ù¡(;jjity conrajns more tanks or dispensers, copy chis form,
Tank lD: (JAíAA øe,I
o In-Tank Gauging Probe. Model:
c:Y'Annular Space or Vault Sensor. Model: _______
o Piping Sump / Trench Sensor(s). Model:
o Fill Sump Sensor(s). Modd:
o Mechanical Line Leak Detecror. Model;
o Elecrronic Line Leak Decector. Model;
a Tank Overfill / High-Level Sensor. Model; .____n__
a Other s eci 'e ui ment e and model in Section E on Pa è 1\.
TanldD:
o In-Tank Gauging Probe. Model:
o Annular Space or Vault Sensor. Model;
o Piping Sump / Trench Sensor(s). Model:
o FilJ Sump Sensor(s), Model:
o Mechanical Line Leak Deœctor. ¡vlode]:
o Electronic Line Leak Derector. Mode!:
o Tank OvertilJ / High·Level Sensor. !vfodel:
o Other (5 ecify e ui ment tv e and model in Section E on Pa è 1).
Dispenser ID:
o Dispenser Containment Sensor(s). Model:
o Shear Valve(s).
o Dìs eoser Containment Float(s) and Chajn(s).
Dispenser ID:
o Dispenser Containment Sensor(s). Model: _____n._
o Shear Valve(s).
o Dis enser Containmem FloflI(S and Chain(s).
Dispenser ID:
o Dispenser Conrainmem Sensor(s). Model;
o Shear Valve(s).
o Dis enSèr Containment Float s and Chain(s).
Include information for every tank and dispenser at the facility.
C. Certification -1 certify that the equipment identitied in this d.ocument was inspected/serviced in accordance with the manufac1UI'êrs'
guidelilles. Artached to this Certitieation is information (e.g. manufacturers' checklists) necessary to verify that this information is
':ûITeC( and à Plot Plan showing the layout of monitoring equipment. For any equipment capable of generating such reports, 1 have ¡~Iso
;ltrachèd a copy of the report; (check 11/1 that apply): QSystem set-up 0 rm his! y rer! rt
Tedmiclan Name (prim): ~~ <:¡ R-I u¡t Signature:
---.------
l'c:nÜl.L'arion No.: '7o~ ~C)C,01 License. C61/D40-: j: ~..09850
TèslingCompany~ame: RICH ENVIRONMENTAL PhoneNo,:(661 ) 392-8687
Sire .-\.dLiress: Å1teo -~C,(2.. ßù¢L CJI~ -G.,Us (jI.4P- ßA~ Date ofTesting/Servicing: JpJ ..Þ...._j_f?..~
Page 1 of3
03íO 1
/\1,) ¡jjwrjll~ System Certi1ïcation
Û. Kcsuhs 01' Testing/Servicing
~SOlf\\ Jfç V çrsion installed:
~'ljlèfL: (lit: ïol1owin..r checklist:
¡r ~. èS I 0 No:" Is the a~dible alarm 0 er~tio!lal?
I ~ .\ ~ 0 No'" Is d1e visual alarm 0 eratLonal?
\ ~2;~-'" I D Nù* Were all sensors ~isua!l ins ected, fu~ctio~al1y tested, and c.ontirmed ° era.ti,onal? . ____
\ IV'ì~ D No" Were all sensors ll1stalled at lowest pOint of secondary contalrunent and posLtloned so that other equlpmeLU will
\ nor huertère with their 1"0 )er 0 eraÜon? .
\i O\~S 0 ;No'" If alarms are relayed [Q a remote l11onitoring station, is all communications equipment (e.g, modem)
I cí N/A operational?
(] -\ .:s D ~~* For ~re~surized piping systems, d~e.s the ttirbine allt~m.atical~y shut .down if the piping secondary containm~lH-
I]i{ N,A monnonng system detects a leak, falls to operate, or IS electrically disconnected? If yes: which sensors inirialL'
positjve shut-down? (Check 'Ill Ihm clpply) Q Sump/Trench Sensors; 0 Dispenser Contaillil1em Sensors.
Did 'ou confirm ositive shut-dùwn du.e to leaks and sensor failure/discofll1ection? 0 Yes; 0 No.
D No* For rank systems that utilize the monitoring system as the primary tank overfill warning device (i,I;".. 11(\
œ; NiA mechanical overtìll prevention valve is installed), is the overfill warning alarm visible and audible at the (¡¡nk
till oimes) and 0 eratíno )1'0 erly? 11'so, at what ercent of tank ca ací does the alarm triú 'er? l~il)
Was any monitoring equipment replaced? If yes, identify specific sensors, probes, or oTher equipmem replacC'd
and list the manLlfactw'er name and model for all re lacement arts in Section E, below.
U \è':;'¡; Was liquid fOlilld inside any secondarycontairmlent systems designed as dry systems? (Check all Thaf appÖ) 0
_L Product; 0 Water. If es, describe causes in Section E, below.
~)r.~~s 0 No* Was monitorinO' s stem set-u reviewed to ensure ro er settinas? Attach set u ¡icable
M' Y ö 0 No* Is all monitorino- e Lli mem 0 erational ermanufactLlrer's specifications?
,;- 1JJ S.:crioll E below, describe how ~nd when tiH:se deficiencie~ were or will be corrected.
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£. CUÜl1nents:
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Pßge 2 01'3
03/01
r. l.:¡{-"f;,\n~'; G¿\uging I SIR Equipment:
O~heck this box if tank gauging is used only for inventory contl"l)l.
I¥ Check this box if no tan.k gauging or SIR eqLtipment is installed.
""
This sèc¡ion must be COl1.1pleted if in-tank gauging equipment is used to perform leak detection monitoring,
C(Ji¡'~dè Illè Îùllowinu checklist·
, '~
~~_~_ ,'S U No" Ha~ aU input wiring been inspected for prop~rentry and termination, i.ncluding testing for ground faults? I
U ì':S U Nù* Were all tame gauging probes visually inspected for damage and residue buildup?
0 Was accuracy of system product level readings tested? --.--
0 . , No*
1. c'S
o-:\~.:s I 0 Was accuracy of sysœm water level readings te~red? -
No*
o Y<':s I U No" Were all probes rèÌnstalled properly?
@__Y cS __n 0 No* Were all items on the eqllipmem manu.íàctuter's maintenance check]ist completed?
-- .
" In file ~éèrjDn H, below, describe how and when these deficiencies were or will be corrected.
./ PvCt OJ.) ~ MI1vfTM.. ~
G_ 1.int Le'ìk Detectors (LLD): C! Check this box ifLLDs are noC installed,
CLJlll¡jièH:' tilt' following ched:.hst:
U Yè':3 0 No* For equipment start-LIp or annLlal equipment certification, was a leak simulated to verifY LLD perfonnancc'ì
0 N/A (Check all thaI apply) Simulated leak rate: 0 3 g.p.h.; 0 0.1 g.p.h; 0 0.2 g.p.h.
0 Yè$ 0 No* Were all LLDs confirmed opèrational and accurare within reguJatory requiremencs? j
0 Yes 0 No* Was me resting apparatus properly calibrated?
0 Yes 0 No'" For mechanical LLDs, does the LLD restrictproduct flow jf it detects a leak?
I 0 N/A
---
0 Yes o No* For eJectronic LLDs, does the turbine automatically shut off if the LLD detects a leak?
o N/A
0 \'es o No: ¡ For electronic LLDs, does the turbine autoI!latically shut off if any portion of the monitoring system is disabkd
ON/A Or disconnected?
0 \'es 0 No* For electronic LLDs, does the turbine automatically shut otIif any p0l1ion of the monitoring system maltlmcrions
0 NiA or fails a rest?
f--.
0 YèS 0 No* For electronic LLDs, have all accessible wiring connections been visllaJly inspected?
0 N!A
0 Yes 0 No* Were all items on the equipment manufactur~r's maintenance checklist completed? I
.-
.,' in f111;' Section H, below, describe how and when these d~ficl~ncles were or will be corrected.
1-1. Còrnmems:
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.. -_._----- --
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Pa~e 301'3
03/UI
-; Ì\'lDÜiH}¡,illg SYSIem Certincation
"
Sit.: A.cidness: ~ L-tAJ AJ yC;
UST 1VlonitQring Site Plan
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Dale map was drawn: ,!2J ~ V 'f.
Instructions
If) (Ill aln:ady have a diagram that shows all required information, you may include it, rather than this page, wirh your
Monitoring System Certification, On your site plan, show the general layout of tanks and piping. Clearly idt:ntit\
IOCJlÌùllS of the following equipment, if installed: monitotlng system control panels; sensors monitoring tank anrn,\hn
spaces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic line kak
dèl<;;~\Ors; and in-tank liquid level probe~ (if used for leak detecÚon). In the space provided, note the date this Site Plan
\\<1>: prepared_
Page _cf____
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MON~TOR CERT. FAILURE REPORT
SITE NAME: ~ t:.IAJ AJ \./5 A (Z.Co
I
DATE: I{)-~-ùt.-¡
SITE CONTACT:
CITY:
TECHNICIAN:
ADDRES S :
THE FOLLOWING COM?ONENTS WERE REPLACED/REPAIRED TO COMPLETE THE MONITOR
CERTIFICATION TESTING.
LIST OF PARTS REP¡.ACED/REPAIRED: .
REPAIRS: A)ø.AJ1í..
LABOR: AJðu~
PARTS INSTALLED: ;tJ ¡) µ í£
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MONITORING SYSTEM CERTIFICATION
For Use By flll Jurisdictions WiThin the Stale of California
.-ltl/¡'¡oriry Cired: Chi/pær 6.7, Health and Safety Code; Chapter 16, Division 3, Title 23, Calijornia Code ofRegulmions
.r',
Tbis l(,nn lllLlSf be Llsed w document testing and servicing of monitoring equipment. A separate cenification or reran 11.1l1st be ¡;n'epal'ed
ror_"'uLÌl moniwrirw. sysrem control panel by the œchnician who performs the work. A copy of this form must be provided to the t:01nk
Sy,;tèll1 oWller!operarof. The owner/operator must submit a copy of this form to the local agency reglllatiµg UST systems wÜhin 30
Lbys of [ö[ datt.
A_ GëíH~rallJlformation
FatiliLy Name: .:::.r oH ÅJ JV Y rS
Silè _-\ddrèSS: _.~l..2- ßu.. (4<-
fl (J..(i.Q
~ u.J 'F.~l.AJ1)
OCT 2 EBlªgo.~o':__n____._
City: -f3Ai.lflZg1%:ûf? Zip: _______..-
Contact Phone No.: (
Date of Testing/Serv icing: -'tU Í-/ _Q!:{
f8.cÙil) Comac¡: Person:
jVL11~è.·lvlod,,1 of Moniroring SYStem: -rAJ (uJ.J ,S-I ()OO
R. lnvènHwy of Equipment Tested/Certified
c:.1¡_",·I~ I.!I~." J2.fÙ riace boxes [0 indÌèùre s eci!ic It ui me \[ ius ¡ècred/sen'ÎCed:
!li-T:y:UD:__JJ...N-l- i"~ ..;., M ~~~ TankID: PrsM -"tl_____
¡'II C1! !n-Lmk ~augjng Probe.,. Model: MA'- t æ1n-Tank Gauging Probe. Model: ..AA4-1
I U Annular ~pacc or Vault Sensor. Model: 0 Annular Space or Vault Sensor. Moclel:
I ~P1Pll:g Sun:p i Trench Sensor(s). Model: -'Íþj(,Al1 .-¡:~ ¡:¡¡.;þjpìng Sump J Trench Sensor(s). Modd: fpûu.J ..,:~___..
o J ill ~Ul1lp Sensor(s). Model: 0 Fill Sump Sensor(s). Model:
iJl"'"!\kcÌl;mical Line Leak Detector. Maciel: R'GO :)A(#4 cJ1\1echanical Line Leak Detecror. Model: Q$p ~
o LkL'rwnjc l.ine Leak De!eclOr. Model: 0 Elecrronic Line Leak Detector. Model:
o LUlk Owr!Ìlll High-Level Sensor. Model: _ 0 Tank Overfill J High-Level Sensor, Model: .
Q LJ.r}:¡~'r ~s .èci!\' è ui )n1l'·nt r' e and model in Section E on Pae 2 . 0 Other (s eei', e ui ment t e and model in Section E on Pa ~ 2).
Tyk lD: 11 ,.,} ,- V'ì.. S LtA~ TaßldD:
i1ð' in-rank Gauging Probl'. Model: MA.A,. -lOIn-Tank Gauging Probe. Model:
I 0 _-\1inulaJ' Space or Vau]! Sensor. Model: 0 Annular Space or Vault Sensor. Model:
!¡ IJ!"'Piping Sump / Trench Sensor(s). Model: '1-"" C;øc) -Ç1.AAtr 0 Piping Sump J Trench Sensor(s). Model:
I, 0 FjjJ Sump SèJ1S0r{s). Model: 0 Fill Sump Sensor(s), Model:
I MkCh:illica! Line Leak Detector. Model: 0 Mechanical Line Leak. Dereeror. Model:
o UC":IrùlÙC Line Leak Dèlecror. Model: 0 Elecrronic Line Leak DeteeIOr. Model:
I 0 LUlk Ov<;rfjjJ I High-Level Sensor, Model: 0 Tank Overtìll / High·Level Sensor. Model:
1-º9[j¡èJ' (~P'èLit\ è( ui menr ry e and model in Section E on Pae 2). 0 Other (s ecify e tI i ment I e and model in Sl'ction E on Pa
I Disµenser ID: I .. t.. _ Dispenser ID: 'ì- <6
Œf'Uispelbèf Comainmenr Sensor(s). Mode!: NO AJ'" ~Dispenser Containment Sensor(s). Model: ÄJ(J .v~
¡ iYSlièJf Valvèl$), 1.:1 Shear Valve(s).
I _9L~L~Q.è_li~er Comainmenr Floal(s) and Chail1(s . 0 Dis enser Containment Float(s) and Chain(.:;).
i Dì$¡kJlser m: 1- l.( Dispenser ID:
i¡lYDisjJei1Sa Comainmem Sensor(s). Model: AJdAJ'Í! 0 Dispenser Containment Sensor(s). Model:
II IY'Slie;,¡r ValYè(s). 0 Shear Valve(s).
II 0._: Disp_~n~çr COl1lainmenr Float(s) and Chain(s). 0 Dis enser Containment Float(s) and Chain s).
I 1?~pè1lSe[' W: S ..ç. Dispenser ID:
¡II'I (!'f DiSP. ':llS.or Conrainmem Sensor(s). Model: .A.J U~ 0 Dispenser Containmenr Sensor(s). Model:
llVŠ:tk~:Œ V¡JvèlS). 0 Shear Valve(s).
~gD~~~n~èJ' ÇOJ1lainmel1f Flour s) and Chain s). 0 Dis enser Containment Float s and Chain(s).
'lr'lhè Ú¡cjJiry comajns more tanks or dispensers, copy this form. Include information for every tank and dispenser at the faciliry,
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C. Certification -1 certify that the equipment identitied in tllis document was inspected/serviced in accordance with the manufacturers'
guìùdìlles. Arr¡lched to this Certification is information (e.g. manufacturers' cl1ecklists) necessary to verify that this informntiol1 is
~ûrn~~( iilld a Plot Plan showing the layout of monitoring equipment, For any equipment capable of generating such reports, .[ have ¡dso
:Hi¡¡chd a copy of the report; (check aJ/ 1JIIl1apply): Q System set-up 0 AJ' 1 history re rt
T.::c:!u1Íciall Name (prim): ~ ~~ '\J .-q CA,.J- Signature:
---.-.------..
Cercilkaliol1 No.: 04.(( 2:h'O/1 '·3
License. N
C61/D40- #809850
Ia.
Phone No.:(661 ) 392-8687
Date of Testing/Servicing: L/ 1_) f2!t.
Tesrlng Cùmpany ~ame: RICH ENVI R ONMENT AL
Sih: A..il1rï:ss: .A.ûo -~c:,(2 ßu &Uo""'AJS (JU/p-- ~f1,~ oL
Page 1 of3
OJ/OJ
M.ùüjwrjng System Certification
fV, .H..;SliÜS 91' Tesring/Servicing
Sù1r\\ ;if\." Versiûn Inscalled:
rr-C~'ijièf(: [he followiua checklist:
II ~l2-. è~.' I 0 No;" Is me audible alarm 0 erational?
\1" 'Y, \ ~ U No'" Is dlè visual alarm 0 erational?
[~\;~:--I 0 No'" Were all sensors visual! ins ected, functionall tested, and confiI1ned 0 era.Öonal?__~1
\.¡ ,- \~ 0 No" Were all sensors installed at lowest point of secondary containment and positiolled so that other equipment will
I not imerfere with their ro )èr 0 eration?
Ii u -:-\~-s O/No* If ala.rms are reiayed (Q a remote 1110nitoring station, is all cOl1ununications equipment (e.g. modem)
I / ~ N/A operational?
l-¡¡-\ ÇS 0 No" For pressurized piping systems, does the turbine automatically shut down if the piping secondary conraiJ11n~lll
III 0 N!A moniroring system de1:ects a leak, tàits to oper~, or is e1ectrically discollnected? If yes: which sensors initiate
i posirjve shut-down? (Check all ¡hat apply) [!' Sump/Trench Sensors; 0 Dispenser ~~taillmem Sensors.
!I Did 'ou confirm ositive shur-down due to leaks and sensor failure/disconnection? l1rY es; 0 No,
ir 0 ie, 0 No" For rank sysr~ms that uri1ize the monitoring system as the primary tank overfjiJ warning devicè (i.è, Ill)
i. ~N/A mèchanical overtìlJ prevention valve is installed), is the overfill warning alarm visible and audible at [he Lank
I tìll oim(s) and 0 eratíno )1'0 erly? If so, at what ercenr oftaflk ca aci does tlpe alarm triv"er'? 1~'I)
I U --\ 2~'i; Was any monitoring equipment replaced? If yes, identify specific sensors, probeß, or other equipment replac~d
i and Jist the manutàcturer name, and model tor all re laccment arts in Section E, ~elow.
I U Y.;::;'" Was liquid found inside any seco.ndary cont~inme~t systems designed as dry syst~ms? (Check all That apply) 0
I Product; 0 Water. If es, descnbe causes m SectlOn E, below.
~Jy ò 0 No* Was monitorina s srem set-u reviewed to ensure ro er settinas? Attach set u licable
sf Y èS 0 No* Is all monitorina e ui mem 0 erationa! er manufacturer's specifications?
., in S~'criOll E below, describe how and when these deficiencies were or wilJ be corrected.
f. CüHHnemS:
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Page 2 of 3
(U/OI
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r1I' ChèCk this box if tank gauging is used only for inveotory control.
o Check this box if no tank gallgíng or SIR equipmem is insralkd.
. 1,. 1~_rLì1l1: G"uging / SIR Equipment:
This sèc[Ìon must be COl1.1.pleted if il1.~tank gauging equipment is u.sed to perform leak detection monitoring.
Cû..Q.!'lè rile fùllowinu checklist·
¡ ~ .~
...
0 \'·....:.s 0 No: < Has all input wiring been inspected for proper entry and termination, including testing for ground faults? I
----... Were all mnle gauging probes visually inspected for damage and residue buildup?
0 Yçs U No"
0 Was accuracy of sysIem product level readíngs tested? ----.
0 Y,-'5 No*
O~ç:.èS \ U No" Was accuracy of syscem water level readings tested?
o Yè~ 0 No'· Were all probes reinstalled properly? :1
~_. 0 No" Were all items on the equipment manufacturer's maintenance checklist completed?
o YeS
". 111 fiH: Sc:crion H, below, describe how and when these deficiencies were or wiU be corrected.
G. Lint' Le'll( Detectors (LLD): "Cheek this box if LLDs are nor installed,
CO)Ü¡) ef(' {It.' 0 OWIfJ~ C e ~ I :
l!Í Y èS o No* For equipment start-up or annual equiproe~ertification, was a leak simulated to verify LLD performancè')
ON/A (Check ClLl tha, apply) Simulated leak rate: 3 g.p,h.; 00.1 g.p.h; 00.2 g.p.ll.
-~y èS 0 No* Were all LLDs confirmed operational and accurate within regulatory requirements?
rt ), èS _.
0 No'" Was me testing apparatus properly calibrated?
-ë( Y èS o No* For mechanical LLDs, does the LLD restrict product flow jf it detects a leak? I
o N/A
1
0 YeS o No* For ekctronic LLDs, does the turbine automaTically shut off if rhe LLD detects a leak?
[?' N/A
~. For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabkd
o \'è$ o No*
ær NI A or disconnected?
r···· YèS i}NO* For electronic LLDs, does the turbine amomatically shut off if any p0l1ion ofÙ1e monitoring system malfunctions
u
NiA or fails a test?
[J Y è5 o No* For electronic LLDs, have all accessible wiring connections been visuaJly inspected?
'j r:Ý NlA
..
~ \'èS o No" Were all items on the equipment manufacturer's maintenance checklist completed?
. ---
j f II . a h cl-rst
,~. in dll; .s~ccjon H, below, describe how and when these deticiencies were or wiJ) be corrected.
H. Commems:
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Instructions
If YCIl[ already have a diagram that shows all required information, you may include it, rather than this page, wirh your
Monitoring System Certification. On your site plan, show the general layout of tanks and piping. Clearly idcntíj\
locmious of the following equipment, if installed: monitoring system control panels; sensors monitoring tank annular
Sp,Jces, sumps, dispenser pans, spill containers, or other secondary containment areas; mechanical or electronic lín.e kak
dt;)le..;tofS; and in-tank liquid level probe~ (if used tòr leak detection). In the space provided, note the date this Site Plan
\\a~ prepared.
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DATE & TIME TEST IS TO BE CONDUCTED Q 0
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