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Site Addre99: I`-'�.4 ��C".1.`. '� / a <br /> ` ��- �• .r.�.,. ' ` Date of Testing/Servicing: <br /> �. Results of TestittglServicing DRAFT <br /> 5ofhvare Persian Installed 1 (} <br /> Complete the itrtlowls:g checklist: <br /> a <br /> s ❑ No* is the audible alarm operational? <br /> ❑ No• Is the visas!alarm operauoaal? <br /> ❑ No' Were all aCOM vistsatly impec�d,ftmcfi(lmlly tested,and confnmed operataonal? <br /> Q NO Ware all sensors installed at lowest point of seenndary contaixurw*and positioned so that outer equipment: <br /> nor interfere with their operation? <br /> 0 No` If alarms are relayed to a remote monitoring station, is all communications equipment (e.g. modim) <br /> IYIA operations!? <br /> 0 l`i'on For prcasu�ed piping sys+cass,does the 12"ine auwsbau ally shut down,if the piping secondary c urteix=ent <br /> �J NIA monitoring system detects a leak,falls to operate,or is electrically disconnected? If yes: which sensors initiate <br /> positive shut clown? (Cheat all thataP,P1),XS Wn`h Sc=m;)Dispenser Oxudurnent Sensors. <br /> mid you confuse positive slam-down due to!talcs read sensor f8d ur&scoonection,7*Yes; 0 No. <br /> Q Yes 0 No• For tank systems that utilize the monitotwx system as tfzc prir�ry tenic overfill warning device (Le. no <br /> NIA Wer-hanks!overdli preverstion valve is installed).is the overfill yarning alarm visible and audibie at!lire tank <br /> M s and oprsating properly? If so,at what percent of twk capacitydoes the alarm trigger? <br /> Q Yes• Na Was anymonitpzing equ4mmt replaced? if yes,identify specific sensors,probes,or other equiprarnt replaced <br /> and list the sa&mdacbxm DA=and model for all replacement parts in Secdon E,below. <br /> Yea' Q No Was liquid foinside any aesondsry ay X=deai"adgued as dry systcrm? (ChOwA all;liar apply) <br /> Product; War; If yes,describe causes in Section E.below. <br /> Yes 0 No* was moui sOring systm set-up reviewed to ensure proper settings? <br /> LX Yea No' is all mnnittdul sgtsiprrscrrt operatiottel per unnufacturcr's specifications? <br /> 'In Section E below,describe how And When these deficiencies were or will be corrected. <br /> E. Comments: c l <br /> r <br /> ^4 <br /> S <br /> cAM-a t Page 3 of 3 <br /> w+ns� <br />