HomeMy WebLinkAboutUST REP. 10/22/2004
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OCT. 22. 2004 11: 09AM
NO. 5388
MONITORING SYSTEM CERTIFICATION
For Use By A.11./ur~djcri(J11S Wilhih {he Slall¡ cfCalifornìt1
A,ulhol'ity Cired: Chapter ó.7. Health and Safery Code: Chapter 16. Vivtsit;m 1 Tírle 23, California Code of RefU¡a~ìons
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Thi.s form tnUSt be used to dQC'l.UD.ent resting and serv1ci.ng of monitonuf1f equipment, A separate certification or TC.1H2IT..mU.og. be prl¡,plU"e"
for each monitoring ~vstf;11'} control Danel by the technician who peñonns the work. A copy afrhis fonn must be provid~d ,0 the tam
system awuer/opdTator. The owner/operator must submit a copy of rl1ís form to the local agency n:gtllati.ng UST systems within 3(
cblys of ¡est !Ù\le,
A. General Information 0 ~ ( .
Facilìty Name: {)~Ç , !,;)e..~~
Site AlidTcSs: Á.,o( L. ~Þ- vV\.Arl e 4 .
Facility COIllaCt Pe~on: f;(\ AA ~
Ma.keJModeJ of Monitoring System: ~ A-W.\-
B. Inventory of Equipment Tested/Certified
Chellk t!1I :r ra riate &cI:s:a to Îlldi'~tc 5 . C 111 DlCDt ins cc;icdIs~t'YÏI:Cd;
Bidg. No.;
City: þø..~~(¿(J.. Zip: ~g5 t:Z
Conta.c~ Phone No,: (~( t;$~iS - ~3.
VÞr-O~ Date ófTeSting/ServiOing: lQ./Z2 I~
Tank ID: D~~ Tank!D:
Q In-Tank Gauging Probe. Mode); Q In- TIUlk Gnuging Proèc. Mod~¡:"
.. A11n.ufar Sp¡u:e or Vault SetlSOt. Model: I.,.A-LlS Q Annular Space Qr Vault Sensor. Model:
it Plpìn~ S!,J.J1\p ITre.Qch S~of(5). Model: g ~"t- 0 Piping Sump f1rench Sensor(s), Model:
o pm Sump Scn.w((¡¡). Mode!: a Fill SUJnP Sensor(s). Model:
. Mechanical Line Leak De~tor. Model: ~ j \i:...-r a Mechanical Line L= D!:~ctor, Model;
o Eleçu-onJc Line Leak Detector. Model: Q E}cÇtfoll.Ïc LWe Leak Dolecror, Motkl:
o Tat¡k Ovc::rlilll Hißh·Lcwe! Sensor. Model: 0 Tank.Ov~rfilll High.Uvcl S.ms.or. Model:
C ec' e uí mf:l1t 0:: and model in S¢etioo E an P c 2 . C Otho::r cc' ui ~ c and D).Odcl in Section E on Fa e 2),
TlU1k rD: Tuk ID:
o en·Tank: Gaugin; J?robe. p."fOl1el: Q In·TIIIÜC Ge.U¡ing Probe. MOGel:
Q Annular SpllQO or VlllLlt SetLWC. MQdc;I: a A,MuhIt Space or Vault Sensor, Modol;
a Piping Sump J Treni:h SeJlS01'(s). Model: Q Piping Sump I Trcnçh Sen;or(s). Moclel:
a FiH Sump Sc:nsor(s). Model: a FUI Sump SenSOt'(s). Model:
Q Mcchllllical Line leak DeteCtor. Mode!: 0 Mcçbønlcal L~e Leak Dctcttor. Model:
o Electronic Line Leak Detector. Model: a Electronic Liøer ~aIc tkt~tor_ Model:
Q Tank Ovc:diU / Higlt-Lcvc:l Sensor. ~odc:l: Q Tank OverfiU I High-Level Sensor. Medel:
a atbcr (s ee' u' Ø1C11t c and o10dcl in SectiQll£ OI\ P e 2. a Other e' nt e and xnodel in Section E 011 Pa c 2.
D;ùpenS'fJr ID: Q\~ Dfspeöser m:
II DIsp~ Conæinmc:nt SCIISOr(S)- MQdel: ~ a Displ:')$er Containment Sensor(s). Modd:
.. ShcwVa1vc(~). Q Sh=:r Va.l.V¡;(3).
. Dis nscr Coutainfw:nt Q D' ct\$ét CoDtèiI1tnent Flo s aorl Ch.aic.(s .
J)bpeas~ tD~ þGl,-'" ~þ\. Dupenser ID: '
.'Dispenser Containment Setl$or(s). Model: f'of" 0 Dispenser Cont:lÍmnent SalSOt(S).. Model:
foII'Shcar VaiY<:(S). 0 Shear Valvc{s).
.It D' enscr Containment Q Di ewer Containment Flo $ and Chain s .
Dbpenscr ID: Dispemer m:
a Dispaaer Co~t SCDSQt(s). Model: Q Dispt;nSet' Conblinmcnt Sensor1:s). Modol:
o ShCllt Valve(a). 0 ShoOt Valve(s).
QDis ConuWunc:lJ[ FIo .s and s). Q Di CItJ$er CoutBÏI1mcnt Float(s 'I1IId CIuIIn(~ _
-Ilthe' tàciJity contains mon= Ianks QT dÏspC7Js=I" copy tIü~ f"nn, !l1c1u& inful'W~ for 1:Nt::ry W1k and d¡¡¡. CI.1&U at thi: fucllity.
C. Certifi~tion. I çertlfy tbat the equipment ¡d~~t!.fied in th.!:I document was htspectlld/rerv~
guidelines. Attachod to tWs Certification Is lu(ol'1Qtiol1 (e..g. RUUluW:turm' c:hcddfsi$) ae
CDrl'ect And a P1..t Plan showing thl! layout of mOQitoriug rquipDlI!Ilt. For any equip !;.II.
artac;bcd a eop)' or the report; (chd øIl thm ( lIJ1y)! a System set-up Q AlanD h
Technician Name (p¡:h1t): _Ed McKee Siin~e,:
Certification No.:
0"2.--0 :5t.'D
LiceD.iC. NQ,: _A738065
Phone No.{}60_)_956-0024
Date oC'restíng/Servicing~ tv I'll. / ð4-
'resting Company Nam~; _Tn-State Environmental
Site AddreSs; . -Mol {¿l~~ fv:'.f}{¡ e..
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03101
Monitoring System Certif1cation
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NO. 5388
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D. Results of TestiJ;1g/Scrvicing
Sottwõlft Ver3ìon [nstnl1ed:
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~ ill Ycs·
Com lete tbe fa/lowlna checklist:
If Yes 0 No· Is the audible <11M'n 0 e¡atioœl?
Yes Q No· 1s the vÍ5ual alarm 0 erauonal?
Yes I CJ No" Were aU sensors visual1 ins ecæd, functionaLl tesæd. and confirmed 0 enniOrJal?
y~s a No· Were all sensors installed at }cwe:¡t point of secondary concaú1meQt and pOsJt10ued 50 (bat ocher equipIl.leJlc wi!!
nOt mterfere with their roper 0 era.eion? I
If alums are: relayed [Q a remote aio[litoring staüon,' j~ ¡¡II communications equipment (e,g, modem) I
operadOllal? i
For pressurized piping systems., does the œbiné ð.utamatÏcally shUt down jf the piping secondary c:ontainment
monitoring system deteC'tS ¡ leEk. fails to operate, or is electrically discoIUlected? If yes: whìcb sensors initiate
positive shut-down? (CMck all rhat apply) 8 Sumprrrenr:h. Sensors; III Dispenser Comaínm.ent Sensors.
Did. au coofum POsitive shut-down due to leaks and s~sor (:a.ilure:/disc:onn~ctiQn? !lJ y~s; 0 No.
a No" for tnrtk systems that utilize: the monitoring system as the primary tank ovc:rfill v.-a.rning device (i.e. no
fJJ N/A mechanical overflJl prevention valve Is IMtalled), is the overfill WarDÍl1g alann visible aod audìble at we tank I
fill oin s and 0 er<itin ro erl ? lfso at what ercent ofænk cauaci does the Illarm tri er1 %
Was any tT;Ionitoring equipment replaced? If yes, identify specific sensors, probes, or oilier equipment replaced ,
and 1m the wanufactllrer name and model for all r laC'em-em arts ín Section below.
Wa.$ liquid found inside any secondAry contai:nment ~stcms designed ¡¡s dry systems? (Check all cha.t apply) 'CI I
Product; 0 Water. If es, describe causes in Section E. below,
III Yes 0 No'" Was mou.ítorin st~m SCt-U reviewed to ensure 0 er $ett'ÌD s? Attach set u
. Yes Q No* Is aU mon.itorin e uiÐment erational e,f manuf~cturer's s ecit'icat.ions?
.. In Section E b~low. describe h()w and when these ddic:iencies were or win be correc:ted.
o Ye3
a No'"
~ 'N/A
o No"
o N/A
. YèS
c:l Yes
o Yes"
I1a No
o No
J~ ~_~. _,_1
E. Comments: ~ ~.....-v...~ Df~
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OCT. 22. 2004 11: 10AM
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F. In-Tank Ganging I SIR Equipment:
o Ckeck this box if æ.nk gauging 1s used only for i11v~ntory- Control.
.. Cbeck this box if DO tank gauging or SIR equipmemls installed.
This section mU5t be completed if in-tank gauging equipment is used to perform leak detection monitoring,
c
h ~ II
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omplete t e 0 owin~ c eckljst:
o Yes 0 No" H!15 all inpot wiring been inspected for proper enuy and termination, inc!UdÜ1g te$ting for ground fault,5'?
o y~ Q No· Were all tank gaugìng probes v~l!y inspected for damage and resid.ue buildup?
a Yes 0 No'" Was àOC~CY of sy$tCIIl product level readings tested?
o Yes d No· Was acc\lf;1cy of system water level rea~gs tested?
o Yes 0 No" Were aU probes rcÎI1Su!lcd properly?
DYes Q No· Were all i:rems on the equipment manufacturer's maintcn¡mce checklist completed?
* In the Section H, below, describe how and when the$e defic:iendes were or will be corrected.
G. Line Lea.k Detecton (LLD):
Check ihj¡¡ box ifL,LDs are not installed.
CQIDDlete the followine chcckljst:
.. Yes D No· For equipment stan-up or annual equipmen~ certification, WB.! a leak: sinlula.tcd to verify LLD perfonnance?
Q N/A (Che.ck all that apply) Simulated leak rato~ I( 3 g,p.h.; Q 0.1 g.p.h; a 0.2 g.p,h.
.. Yes r:J No· Were aU LLDs confum~d operational and accurate within r<:gu!atory requirements?
Q Yes 0 No· Was the resting appan.tID; properl}"cal.ibra.ted'?
II Ye~ o No·· For mechanical LLDs, does the Ll.D res1rict product flow if it detectS a leak?
Q NIA
o Yes D No· For elec(roDic LLDs, does the rorbine automaticaJIy shut off if the LLD detects n leak?
II N/A
o Yes D No~ Far ðleçt(Ðnic LLDs, does the turbine automatically sbùt off if any ponion of the mOtÚloring system is disabled
a N/A or disconnected?
o Yes a No'" For clecúvDic LLD$, does the turbine automaticòÙLy shut off if any portion of che monitoring syst.ew malfunctions
I!I NI A or fails a test?
Cl Yes Q No'" For elec1I'Ollic LLDs, have all accessible wiring connections been viiJualIy inspected?
m N/A'
I. Yes o No· We.¡e all iteœ:s on the equipment mmufacro.rer's maintenanc~ checklist completed?
'It ÙI. the Section a. below, describe how aud when tbese deficiencies wen~ or wlII be eon~cted.
B. Comments:
(,., .,
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NO. 5388
MONITORING SYSTEM CERTIFICATION
Fo1' U$e By All Ju.,.ìsdìctìons Wirhtn the State ofCaiifornia
A1Jthç,,:iry Cited; ÇhaprltT 6.7, Heal.rh and Sa/try Code; Chcprer 16. Division 3, rirle 23, Califorl1ia Code of RegulaJIOT/$
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This form must be used to docwnenr testing and servicing ofwarutlXÌD.g equipment, A se¡)f.lnlte cenificatÌOQorreoort musl be creroarec
for each mQnitorinF. svstem control Dane! by the technician who performs the work. A c;opy of this form rnwt be provld!:d 10 the ~
SYStem owner/operator. The <>wner/operatQr must s~bmit a copy of tb,;a form to the local agency regulating UST S)'S\I!rca vÄthiI\ 3(
\Þ.Y$ onest date.
A. Gel'J.eral Information
Facility Name: ~ ge~~
Site Address: ~i>1 t..\'S.o:y Mk\6 çk
F3Ciliry ContaCt Pen;on: gf' I-A-i\. L..CY\~
Ma.Iœ/Modd ofMoJÚtoriug Systew: t"æ&-lNeM-l.
_ Bldg. No,:
City: ßAkPo..r6?:l"'Jc-l Zip: ~~
Couta.ct Phone No.: ((.¡Iv' ) ~~- tnp'J,
ft f<ø.t'\,ìC-J 1Ii Date ofTe5ringlServìcing: J.Q..! 2-2../.!!b
B. Inventory of Equ.ipment T ested/Certified
Choelt tIle ,. to ria1<: bos:es to Ùld.iUfc ~ ui mc¡¡t ¡¡,. <:ctcdl.crnedi:
T~"km: orlð6e TanklD:
I) In-Tw GángiLlg Probe. Mod~l: rYI.6Vr 0 !n-TanJc: GQUglng Pro~" ModeJ:"
Q AtlnuLar Spae~ ot'V¡wlt Sensor, Model: Q AnnullQ" Spaç!; Qr Vault $enSQr. Model:
CJ Piping Sump I Trench SeJISOr\s), Model: 0 Piptag Sump / Trenc/I Scnsor(s). Mode!:
I;) Fill Sump SctI3or(,). Model; 0 Fill SlOmp Scnsot(s). Model:
o Mechanical Line Lc:ak Deteácr. Model: Q M~hanical Line Leak Detector. Mod!:l:
Q ElcCT.\'Qn.ic Lin!: Leak Detector. Model: Q Electronic Line Lca1c Dete(;\or, Model:
o Tank Ove:rfilll High-Level Sensor, Mod!:l: 0 Tank ~dilll Higl'l-Lcvel Sttlsor. Model;
o Oth.er e ui t and 1IlDdcl in Section E IlIl Pa c 2 . a Otb.c:r eci i cnt e and model in S~ctíon E on Pa. c 2).
Taqk ID: Taak ID:
o In-Tank GaU;!ng Probe, Model: 0 1n.Tmk GaugìJ1g Probe. Model"
I:] Annular Space' or Vil1!L Sc:nsw. Model: 0 Atu1u111t SplICe or Vault Sensor. Model; ~
a Piping Sump IT~nch Sensor(s). Model: 0 Piping Sump I Treacl1 Sensor(s}. Mod!;):
Q Fill Sump Sc:nsor(s). Model: Ó FUI Sump Sensot(s). Model:
Q Meehanical Lin!; Leak Detector. Model: D Me>::hanlcal Line Leak Detector. Model:
Q Elcclronic Line Leak Detector. Model: Q Electronic Line uak PetcctOC. Mode!:
o TanIc O~rfi\11 High-Leve:l Sensor. Mode!: Q TIIIlk Overf1n/Hìgh-~e! Sensor. Modc:l:
o Other u.i ment c and .arodel in SI:I;IiQn Ii on Pa e 2. . a Other ' ui øMt ~ ami modðl m Section é Oll P ð 2).
Disþensa- ID: Dispe¡¡s::.\" ID:
CJ DispelUCr Containment $ccsOr{s}. Model: 0 Dispcnsa- COÐ.taimnè11t Scnsor(s), Model:
o Shear Va:lvc(s). [J She¡¡(' ValYc(s).
0. Dj cnScr" Contnin.Jncnt PlOp· t:r Contllim-ncnt F1
Di,pet:lScr ID:· DispeDser ID:
I:] Dispensa ConuUnmcnt Scnsoc(s). Model: Q Dispenser Contaiamcnt Sensor(s). Model;
Q Shear Yø.1Vc(s) , (J Sb.earVa!ve(s).
Q D' ens¡;r Containment FIO!lt S IU1d Chain(s . Q Di cr COntninmCUL.f10 s and Ch' s.
Dispcasor J:D: D¡"pensGr ID:
o Dispm60r COtltam.m.e [ Sœsor(s). Model; a Dispc~ Containment Scn$Or(s). Model:
[J Shear Valve(S). Q SheBt Valvc(s).
QDi r Co!1U\.Ïtln1çnt F1 5) anfJ s . .Q ansa- C~ Ploa: 3 'lmd CMI.n(s).
"'If the &cWty contains ¡narc tanIC$ 0'1' ~rs. ,to"y tl1;$ !On:tL Include info.nnatioa for c~ tank IltId diBpcnser at tb" facility,
C. Certification. I ctrtify tbat the 6it\).jpØ1ent ldentiØ£d in this document wu inspeetedlservi
gv.idc:lltI£:i. Abêhcd to tbd Certi1'íCl.tion is inforlbatlol1 (e.g. on.qnLu:tur'¡,n' cheeldi:sts)
corr~( a.ad II Plot P\.an .Jbowing tbe larGot of !ltC/aftoring e~jpm.mt. For ~y equi ca a
attndled a \:øpy o(the report; (c1r~k all that rtpplJ1): (J System ,et.-up 0 A s
Tc:cbn.icÙIl1 Namç (print): ~Ed McKee Signature:
Cel1Ï'ÐecîÚQn No.:
T csting Company Name: _ Tri-S'tate EnviroIUIICntal
Site Mdre¡ss: k1i>t (.;1.$"- 'M~\<- ~.
...-
License.. No.:...,........A738065
Phone No.:(JóO~_gsQ..0024
Date of TestinglServicing: ) D I f:Z..¡ ::,+-
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Moaltoriog Systeb1 Certlfteation
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D. Results ()fTesting/Servicing
SofuviIfe Version [¡¡stalled:
-
Com (ete tbe fol!owinl1; ebccklist:
I . Yes 0 No· [s the audibl~ ,,(arm ocerinioaal'?
Yes a No· Is the visual alarm 0 tional?
Ye5 0 No" Were all sctJSors visuaU insDt;Ç\ed functional1v tasted. and cOlÛumed 0 eratio[¡¡ll?
r:II Yes I Q No" Wcre all sensors instaHed at lowest pai.nt of secondary containment aod positioned so that oilier equipment will '
nOt interfere wÙh theiT ro er 0 er;UÎon'?
Q No· If alarms are relayed to a remote monitoring station, is a.Il communications equIpment (e,g. modern)'
IB NI A opemtional? !
a NQ'" for pressurized piping system!!, doæ the turbine automaÜcally sh1.l1 doVlt} if the pjpiPg secondary containment i
o NlA monitoring system det~c1S a leak, fails to ope.rate, or ìs elect;ric.ally di~connccted? If yes: whïclJ. sensors initiate !
positive shm-down? (Check ell tnor apply) 0 sumprrn:nch SeDSors; 0 Dispenser Containment Sensors.
Did ou confIrm ositive shUt-down d1.le to le1Iks and sensor failu:reldiscoanection? Q Ye5; a No.
No'" for tank systems that I.ltiljze the monitoring system 2.5 the priInary tank overfill warning device (i.e. no
N/A mechanical overfill preventiQn valve is installed), is the overíill w4Iroing alarm vísibla and audible at the tank
flll oim(s and 0 CI4tin ro cd ? If so, at whm ereem of tank ca aci d.o~s the alarm IIi er? %
W3.$ any monitoring equipment repiaced? Ify~, identify specific sensors, probes, or ocher (;quipmeDt replaced:
and lí¡¡t ilic m.a.n.u.facturer name and model for all rc !¡¡cement arts in SectÍan E. below.
W~ liquid found inside any secondary contaimnent syuems designed as dry systems? (Check all chat apply) a
Product; 0 Water. If es, describe causeS in ScctÍon E, below,
II Yes a No· Was mOJÚIorin stetn $et- reviewed to CDsure TO et sertÎn 51 An.ach set u
.IB Yes 0 No· Is all monitorin e U' ment erntional ermannfacturer's's .;!cifications?
.... Iu Section E below. dest:ribe bow Bnd when (hes~ deficieucies were Dr will be corrected,
-
a Yes
a Ye5
I
CJ Yes
I~
o Yes·
ID No
Q Yes"
fiD No
E. Comments:
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F. In-Tank Gauging J SIR Equipment:
o Check this bQX iftID1k gauging is used D1Ù)' for invento(}' contro\.
o Check thjs box )f 110 tank: gauging or SIR 1;quipn'\~\1.[ is i.ost¡¡1{¢d.
TIús section must be completed if in·tartk gauging equipment Is used to perfonn leak detection monitodng.
ComPlete [ e- fo OWIn~ c ec 1St:
.. Yes o No" Has all inpm wiring been inspected for proper entry and terminaÜon, including testing for: gro1md fuu ts?
fA Yes a No'· Were all tank gauging probes visually ingpected for damage: and residuè buildup?
DYes e No· Was accurncy of system product level readin~ tested?
DYes . No· Was acc\U1!.cy of$)'$tcrn watOJ' level readings tested?
. Yes 0 No'" Were all probes reinstalled property'?
. Yes a No· Were aU itero.s on the equipment U1anufuetu.rer's maintenan-ce checklist completed?
h 11 h kJ'
~ In tlre Section H, below, describe hc:n~ and when these deficiencies were or wUl be corl"ecœd.
G. Line Leak Detectors (LLD);
o Check this box jf LLDs ar~ not i.ustaLIed.
c
I te th f¡ lJ
h klist
amplC f: a oWln~ c el: :
o Yes o No'" For equipment sta:r:t-up or aunua1 equipment certification, was a ]eak simulated to verify till pcrformaDce?
o N/A (Check a/I that apply) Simulated leak rate: 03 g.p.h.; 00.1 g.p,h; 00.2 g.p.h.
o Yes Q No" Were all LLDs confumed operational and acéumte withm regulatory requiremønts?
'0 Yes o No'" Was the resting appamtus properly-calibrflted7
a Yes o No· For mechanical LLD!, does the LLD r¢strÎctproduct flow jf it dl::tects a leák:?
o N/A
o Yr.$ CJ No.. .For electronic LLDs, does tbc rorbine automaticaJIy sbur off îf tbe LLD detects a leak?
o N/A
Q Yes Q No· For electronic LLDs, do~ the turbine automatically sbut off if aay porrion of the monitoring oi}'stem is duabled
o N/A or disconnected?
(J Ye$ Q No· For electronic LLD.$, does the turbine automa.tically shut off if any portion of the monitoring system malfunctions
o N/A or fails II test?
Q Yes o No· For electz"onic LLDs, have all accessi~le wiring cQ.r;w.ectiotlS bC'Ctt VÏ$ualIy inspected?
o N/A
Q Yes o No'" Were ail items On the equipment manufacturer's J21aÌntenanc(; c/J.e;c]dist completed?
.. In the Secdon a. below, deséribe bow and wben t11ese deficiendçs were Ot' will be corrected.
H. CO'tnmeots:
t I - Rv ~ \6 "Y\ 0 ~ /¡\J or\A \ð-tl - "\2e.c 'GNvlV\-'€AA 1. ('e,f(-PcÁ VI. ~
~~ <;/ t~v ~~4::: ~~ ~ ~"-4- l<-
&J ~ -1~ .. ( ~¥ v\.c/'~ ( ~("i ... : -+l l '^- ~ s.~.)
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03101
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FAX NO. :7609561015
Oct. 01 2004 08:58AM P3
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FROM :TRI-STATE
. MONITORING SYSTEM CERTIFICATION
FI)I' Un JJÿ AU .lvri4dictÛNø WldUn . Sùnø aICø/iførniø
ArllhortfJI Cl#d: Ch4plu 6.7. Nul", antI &ply CMIl: Cluzptrr J 6'. Dlvb/M), Tílfw 2J, CøJifimtlfJ Cod. 0/ Røgtllt4lolB
This farm ~ be USId IØ doèIW0A1 Þ*Ia8 aød mvloInS ofmonito!'Ûll equ.lpmant. A seoataf.e ðl:rtific:¡ufoJl or t~ort must bit Ji'RDIIJ" ~
ros.,each moqi,òrina lIYIIeIft coftb'Ol ~ by the tec:1mician . perf'oma the work. A cop>, of tbll form must be pI'O\Oâdcd to &hit tank
~.Y$1em owuor/opnW'. The OWNI'/OpemlClr must .ubrnít. çopy of1b.i& 'fonD to the local agcmcy re,u1ltfq tJST syalcm. within 30
~~~ ' .
A. G_en! lDfonnldoa .
Pw1cWt)/'NIIM!I: ~ ~ .ßJ.4Ø.No.:
SiteAddϟ; _- ~ \Cc cl-' ~~ City:~(J. ZJ9:~ .._
FàdlltyConlilç~PersoA: ~~ I~ . CoøtactPhoaeNo.:{ l~' }~~- ~~ .
M.ølMòdetotMOJliI;oriqSyawn: 1..At>t- ~,....l. ~ DaœofT Ì,~in¡lServleÙ1&: Jl.J~~
B. IDveatoJ')' of Eq1llpment teatedIC..-dfted
TaIlUD: ,
g IA-TInk GauIiDI f'Nbo. Madel:
I:J AlmWIt 5J111(:t or Vault SetUIOr, Mod81:
C PlpJDa S\Itnp I Tmw.Þ. SèD$òl(.). Model:
C 11111 Slimp Seuør(S). McIde1:
[J MedaWcallJDe LaJc Doudor.' M:04tI1:
o BtOCU'OSlic UIIG,Lc:aIk Oetector. Model:,
o Tank òweåW J Uigh.tevc18cnsor. Model;
Q orJ&Gr ' ' and. . Sc:cdOllo E ,óö. 1
1'_ ~
C t. T8ak Oaualna PrubG. Model:
g .MøuIar Sp.:e or Vaull SenIOr. . Model:
Q P.lp1Dc s_, I Trcaoh Seasor(s). ModAû:
I;J Fall Sump 9enlOr(I), Model: '
a M~1A! LIne t.~ Detector. Modo!:
C 'EI~B Un, J..I!IAk Detecw, Mod":
Q TanIt Ovcdi.Il/ HJp-t.eY.t ScmsoJo. Model: .
Q 0C1\et. t 0 and madallo SCCTioG B òD PI 2.
IMI,...., ID:
a DispaIscr CcmDùMI",. ScruIor(s):" ~I;
o Slaear VaJ'Yc(t).
C ~~t ¡r .. III\d
DII..-r m:
Q DiSpeI\S«r ~t SI!InAOr(.), Mødc1~ _.
C, Sbcv VaIw(S).
·CDi C
. Dapeuer ID: :
MOcW: 0 DIIpeI\set Confainmant Sen~s). Moctd:
Q Ih- VIIlw(.). C Dear VaI¥II(a}.
..... . Ißd ~ . C D COn&ldmøønl _d alliin
~Jt1U IIGiIiIy CGCûIaI moro ""b ør dJlpaJAd. GCJpy thfa fMm. Include InfonIaWm fi)f I'YII)' IIAk 1114 dJIpcuet at ChI! &alli\y,
C. C.rdflcadøa..1 ur1I~'" ..eqw...-:ntIdtldlW I. tWt ~W. ~ 18 c...wldt thD IUIIJd'atWrå1i'
, ........ AttIcW tø ..... ~ Jt ..~ (.,. _IIIIIa'..,...,· cIMeJd....) . þJ'oouCIoD I.
eM_ ... . 'lot ......~I...1aJÓ1d or ~ ecpIp.w. "01' Ø' ...ul rta, I.. .110
~. ctpJ .,*' ~ (dfd" ,..,.",,): Q SJItaI ..up I;] ry
TfOImiø. mN.me (priaU: ~ MoKeB !l;ip.re: -.'
cmI1'IoIIiQD No.: /Y7__D:J:;-b Låo..,. No.: _.4.7380&5
TtIting~Nam.: TJi..S_~. Phoa.eNo.:L760--J_95CS-0024
Slr.tAddreas: ~p\ ~ ~1It. ~ D8teot'restin8/Serv1cme:.J!Jt.~ IRJ..
TIIDII;IJ)¡-, t'A't~·
C In-TIIIIk OIuaitIa.Probe. . MocIeI:
. Almulnr9~orVlRdtScNot, MadeJ: = ~
. Pipbta~ ITmda Sc:DIoI(.). Model; _ ~
Q FW sump,kaar(s.). I ModOI:
r.:;r Mec:banàl1JDc Lat DettcIof. Modo!:
o B1odrOftIc~ LoåDéftrøCOr. MOcW:
Q, T. ÐvdU I u,...._,,_ SèIDIor:, MIWd: .
a" ,. . ".~'~'" , im4~ídJn~oaBQØ
1'IIaIc Sr'
0,,1'" Tùtt GIIt¡tna Probe. , Modal:
Q ADiWIao SpIce or Vault SenIor: Mo4-I: ~_
Q PJpIq Sump I Tnaah SaIIøJOO. Mo4oJ;
Q PfIl8IIØIP Scaø(.). MocIcI:
Q M.IIcImnioal LIu Leak DcncotDr. Mbd.al:
o Bltx:lfGdic U- Leak ЫeCltor. Model:
Q TIIIk ,n 'Hilh~1 SctnIcw. ~èt:
C Othd' . i If åftt'104 ,ja ÞoticID£ Oft
0iI,...,m:, . maL ,J ", '
. D__ ~ho~eat SlØOI'(s). 'M~: ...... I.\I.'N4
.~ SIar VaIw(.).
M_"""'s,ø.. c:......~
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UI01
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FROM :TRI-STATE
FAX NO. :7609561015
Oct. 01 2004 08:59AM P4
.
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0. RcspaÞ 01 TøtiDcJSvviciDI
Software Vemlon lnsœUId:
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c V.. C No"
. NlA
. VII IJ No·
C N/A
. : g..y'~,
i' :
Q Yet- .No
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03101
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FROM : TR I-STATE
FAX NO. :7609561015
Oct. 01 2004 08:59AM P5
........... -...
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01 I .
F. Ia-Taak Gauginøl SIR Equipment:
tJ Cba:k this· box if tank ¡augin& i, used only for inventoty contral.
. Check dús box ¡fno tIIÙ pûåÏò¡ or SIR equipment Is lMtaUed.
This sa;tiOI1 must be completed if in-taßk p11IÎal ~ipment is used to pcrfonn leak detection monitorin¡.
tØ toll Ia deeIdtI
0....,"" 01V '1 t: ,
eVil g No· Hu aD IDput ~ .... !napeot.rId tbr p.,... emry II'ICI ~ IMlUcIIð& ...n. for around fiwtt.7
CYeI C No" Were"J taaII:: vfauaUy lalpected for 9rœ¡. aad residuo' buildup?,
I:J Yes a Nq' w.. ~.,f~~ Ievdn:adiDøs tatect?
ay. e No' w.. aoøutIIq ofl)'ttem ,.,.œrlcnrel f'IIIIdIDp tested?
c::I Vea a No' Were 1111 pro_ ra:tlM1IUe4IWGpIfIY?
C "1_ a~ Werè all iQ:ma ora" eqaalpmeBi ~s QJÜIt.cIaBace cheakUle CGlDplotod7
· ID the SectIoa a. below. deKriIM bow IIIICI wbm dIae.....neJu ..,e or wiD ~ con-ecœd.
G. LIÙ Leü'D..... (LLD)I
. c:betk thit box ifLLDs In DOC fuWJDd.
CómuJ.,. Qa, lblloMa. dule1J1tm
C y*,* C No' Far aquIprum ;wc;.ap or IIUIUI1 cquipnœat cmdflcll1ol1t was 8 leak øfmu1lted to wri~ Lt..t) petfoon8QQtl?
C 'HIA (CII-" ø/I tht:tI t1NlY) Simúced leak rato; Q 3 g.p.b..¡ C O. t g.p.b; C 0-2 g.p.b.
C YCI$ tJ Nó· Wen an un. ~ed IG4 accurate wiIhiD MBq)mory requJrmnaúø'1
Cv.. Q NolÞ \Vas.dIe. tcltÎðg ..... ¡mapw~cdbnted?
.~. YeiI;' ; tI, No~ . F.er:8lØèbmICal \..LDI. doas drø LLD I88IIt« procfur C Oow it It datocts 111· leak?
,C NlA.
QV.· Q 'No' '~r .I~ Lt.Þt,dc* lb. M'biIao ~Iy Ibut~aif1Þ J.1J) 4eceGIs a leak?
; C'NlA
' . i
1;;1. YOI g:~. Far eJedronic: LLÐt. doea tàe Nrbmo -.omaticaUy IIwI: oil" If IIQY potUolII of the ~ 1IYI\Ia II dlaablod .
, C N/~ I or dilCQ&UMidlld? '
'CYCItI Q,No· . FM e~o LL.D.c. rkIeI Cbt UbiDe euaoDlltical1y sbuI off if any porti()Ð øftho moaitoriDø 8yaWn ~
'Q N/A (If. ~ a teItl
;J V.. g NO- fur eleœnmtç ~ bavo alllIJOeSIiblo wida& 0GIIDIGIåaas bam """"'1)' illlpecfl d?
·.Q,NJA I
CJY. g No* w.. III ... on me eq..UMau1åotunrt·1 ~ checlcUe& ccxaplMed?
.
lit Ja .. SeetI.'R. beIøw. ålcrlbe how ad w"ea 1MIe cIoncì... __.... Or win be c:ol'l'eded.
It CD~Dlaaàl
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