DERR-2024-004450

Publication: WRF -0001
Issue Date: 01-06-15
Supercedes: 01-31-11
C>PVV.♦ Warranty Registration F/~()RKS
F U E llNO CONTA INM E NT SYST EMS aY o~w ,u,u a , co •rAI MMINT IY UIM ■
TO BE COMPLETED BY CONTRACTOR / INSTALLER
C ontractor
Email: /Vl~ ®,Sc,~.(Ovv--
Fax:_i:«~~.,..,_1_-~iet~z_~q~t/~oS~------
Phone: 8'Q1-2'[ Z-t.fqtJI.I
Installation Date: --'-'-l1_-__ )_-_t-....:c3 _______ _
Training Certification Expiration Date: '2-7-Z..~
Distributor: C5~JC.O
IMPORTANT -The Product Warranty only becomes effective upon completion and return of this form to the Marketing Department of
OPW Retail Fueling. (See reverse side for malling). Please return this form within 14 days of site Installation either by mail, by fax (fax number
919-573-9497) or by email to [e-mail].
TANK SUMPS, TRANSITION SUMPS & MANHOLE COVERS
Yes No
1. Were all sumps inspected for damage prior to installation? ~ 0 5. If the riser was cut down, was it measured and cut 1/4'
2. Is the site known to have a high water table? IQ_, 0
below the inside valley of the corrugate at sump riser?
3. How many Tank Fitting Adapters (TFA-4090 or SMF-4E) _(1)_(2 ) 6. Was the cover installed onto the sump riser during backfilling ?
were used? 7. Were the instructions in the product manual followed?
4. Were all compression rings installed on two pie ce sumps? 0 0 6. Was a hydrostatic test performed on each sump?
(if applicable) 9. Was the sump cleaned of all debris?
DISPENSER SUMPS
Yes No
1. Were all sumps inspected for damage prior to installation? Q!I,, 0 4. Was a hydrostatic test performed on each sump?
2. Were all of the stabilizer bars secure? ~ 0 5. Were the instructions in the product manual followed?
3. Were all the provided anchor bolts installed? ~ 0 6. Was the sump cleaned of al l debris?
PIPE & CONDUIT ENTRY SEALS
1. Was the correct size hole saw used on each size entry boot?
2. Were all band clamps secure & tightened, not to exceed
30 in. lbs.?
Yes No
fJ o 3. Were all entry boot nuts secure & tightened to 60 in. lbs.?
~ o 4. Are all pipe & conduit entries less than 15' off center-line?
FLEXIBLE PIPING
Yes No
0 □
,r □
~ 0
!Jl 0
~ 0
Yes No
fX 0
-□ ~ □
Yes No
,d □
~ □
O 1" §(1 ·1/2" O 2" O 3" O 4' Pipe date code, _ _:'l=:...,e~c:.......ct:::...._t,_Z.__._/ 'l-=-=5=------
O UL Approved FlexWorks Single Wall J{ UL Approved FlexWorks Double Wall ~Access Pipe (AXP)
1. What size Piping was installed? O 3/4 "
2. What type of flexible piping was installed?
O Blueline Single Wall O Blueline Double Wall O EN14125 Single Wall O EN14125 Double Wall
3. What type of fittings were installed? o Coaxial O Swivel O Swivel Bolt-On (SBC) ~ Double Wall Swivel (DPC) □ Barbed □ Stainless Steel
4. What type of fuel is to be stored? 'l_ Gasoline o Gasohol o Methanol o Ethanol 81_ Diesel o Kerosene O Fue l Oil O Other _____ _
5. Was the site contaminated prior to install? O Yes A!_ No
Yes No
6. Was all piping inspected for damage prior to & after installation? ttt_ 0 12 . Were all piping connections tightened to the required specification?
7. Were all couplings inspected for damage prior to & after installation? l!l o 13. Was the primary piping air tested?
6. Were all fittings inspected for damage prior to & after installation? _).(_ O
9. Were only approved backfill materials used around the piping? ,kl·' O
10. Were the instructions in the product manual fo llowed? ·r/f-. O
14. Was the interstitial space of the Double Wall piping air tested?
15. Was Access Pipe (AXP) used?
16. Was the secondary left open to atmosphere after testing?
11. Were crossover supports used at all direct bury piping crossovers? A O 17. Were all connections/pipe entries/sumps straight & aligned properly?
CONTRACTOR
I hereby certify that the abo
Product Manuals and have
Copy protocol (1) Contra
eel, a d that I have read the OPW Retail Fueling Warranty enclosed. I have reviewed the respective OPW
0 ntalive on the proper installation procedures for components of the FlexWorks Piping Sys/em.
Contractor's Signature: _.....,,...,,,_,.._,,.....,...,_-=-""--#--"b.l...--------------------------------
Date: -Z.-
OPW Retail Fuelin 70 Business West • Smithfield NC • Tel: [phone] • www.o w loba l.com
VEEDER-ROOT MONITORING SYSTEMS
WARRANTY REGISTRATION AND CHECKOUT FORM (WRACO)
FOR TLS-450 AND TLS-450PLUS CONSOLES
The warranty is not valid unless the registration form is comple ted and s ubmitted electronically to
Veeder-Root within 14 days of installation.
PLEASE NOTE: ALL FIELDS (EXCEPT EMAIL ADDRESSES) MUST BE COMPLETED
BEFORE THE FORM CAN BE SUBMITTED ONLINE
START-UP TECHNICIAN
Ce rtificati on #: •
(Must b e TLS-450 or TLS-4S0 PLUS certified to perform a T LS-
450 or TLS-4S0PLUS startup respectively.)
Contractor Name: C. E' C.o ,J<:.__
Console Serial #:
Installa tion Date (mm/dd/yyyy):
INSTALLATION LOCATION.
Business C ateg01y:
D A irport
~ C-Store
□ Federal Government
□ Fleet Mgmt/Rental Car
□ Hospital
Storage Tank Type : ~ Underground Storage Tank
D Aboveground Storage Tank
0 Both
Oil Brand:
Mana er:
Address :
City:
State/Proy ince:
Postal Code:
Phone:
Email:
STATION OWNER •
□ Municipality
□ P hone Company
□ Terminal
□ Utility
□ Other (specify):
D Check here if same as installation location
Owner's Name :
Address:
City:
State/Province:
Postal Code:
Phone#:
Email:
, WRACO # 50'2. 3'6b5
INSTALLED.COMPONENTS
S-Electronic Line Leak
□ ~xteoded Storage L 2 (3 years)
□ TLS-RF (Wireless)
D • Total Access Option
D Total Control Option
CUSTOMER INFORMATION
I have been trained in the proper operation of this
equipment: YES __ NO --
Name'(PRINT ED):
Signature:
Date:
Title:
INSTALLATION AND JNTmNSIC SA,FETY CHECKLIST
6'J TL&aMonitor is installed indoors in an accessible
loca tion within audible alarm hearing distance.
I
121 TLS Monit or has 12 gauge wire from barrier to earth
gr"aund in the power panel.
~ Power' wires l""e installed in conduit.
~ TLS Mon itor has a chas sis ground connection.
~ Conduits enter TLS Monitor only through pre -fom1ed
knockouts.
~ Monitor-to-probe wiring runs do not exceed 1000
feet.
[2l Sensor and probe wiring is 14 -18 gauge sh ie lded
cable. -.-,
~ Sensor and probe wiring is installed in dedicate d
conduit.
Ix! Sealoffs are installed on probe and sensor conduits
between building and tank. I ~ ~ Prooe and sensor w iring connections in tank area are
installed in1 suitable weatherproof junction boxes.
~ All outdoor wirin g connections for probes and sensors
are sealed with epoxy sealing kits .
I hereby certify Ll1al this system bas been installed in accordance with the
procedures speci fi ed in the published Veeder-Root Site Prep and
Installation manual. I have also r ead all of the warnings and I certify that
there are no intrinsic safey violations due lo improper installation of this
system.
Signature:
Date:
() VEEDER-ROOT ~-
Form No. 576047-144 Rev. B
To d ownload this fonn online, please v isit http ://www.veeder.com/page/Support
TANK INSTALLATION CHECKLIST
TO INSTALLER: After tank instal lation, deliver the Installation Manual with the completed Tank Installation Checklist to the tank owner. Retain a copy of
each for your records.
TO OWNER: After install ation, retain the limited warranty, the Installation Manual and completed Tank Install ation Checkl ist for future reference and to
facilitate any warranty claim. 1-·/ // ..._ ~
INSTALLATION DATE(S): q -'f 7-Z J PERSON COMPLETING FORM: CaA/1 e GI\ ( I J. ~
INSTALLATIOi<JADDRESS: . 660 s } 15(2 • l-\.),, sPr;vra u:flc, itl 8l/lt'i
TANK INFORMATION
Tank type-Single-Wall (SW), Double-Wal l (DW)
Tank Usage (Fuel)-Fuel, DEF, Pipeline Sump
Tank Usage (Water)-Potable Water, Water Collection
Tank Usag~ (Wastewater)-Grease Interceptor, Septic, Industrial Waste-
water/Chemical
Tank Usage (Oil/Water Separator)
Nominal Tank Diameter-give in feet
Nominal Tank Capacity-give in gallons or liters (and note which)
If applicable, UUULC # (read from tank label)-yes or no
SITE INFORMATION (See Section 1)
Primary backfill meets Appendix C requirements -yes or no
Secondary backfill material will be used -yes or no
Secondary backfill meets our requirements -yes or no
Geotextile will be used -yes or no '
Excavation -shored or not shored
Tank wil l see traffic loads (H20 or HS20) -yes or no
Hole condition -dry or wet
Anchoring system will be used -yes or no
If applicable, anchoring system used -dead men or anchor slab
PREINSTALLATION INSPECTION AND TESTING (See Sections 3 and 4)
-Shipping damage -yes or no
Loss of vacuum -yes or no
Monitoring fluid visible on interior of tank-yes or no
Monitori ng fluid visible on exterior of tank-yes or no
Requi rements met for double-wal l tanks shipped under interstitial
vacuum -yes or no. If yes, record the value.
Record fluid level in reservoi r for double-wall wet tanks
If required, tank passed pressure/soap test -yes or no
XERXES®
BY SHAWCOR
TANK#1
10'
TANK#f
Yes .
A)O '
v~.s
Ve.-;
j(..<;
~e+-
ye,, s 11
cl~~
TANK#1;
(\.)0 1
NcJ -
NO
-17-t
--
TANK#2 TANK#3 TANK#4
ID' 10' 10'
TANK#2 TANK#3 TANK#4
Yes I .¼s Jk5
NO .A)O N'i>
Yes Yes ~5
Yef ye5 ye5
Y~.s Yt-5 y~
\.J<-t-vJ<-f-u~j-
Y~S v~; >-i> c\~~ cleAt ,. ~-· A,«~lll'W ......-·vr
TANK#2· TANK#3 TANK#4
NO NU A.JO
NO No NO -
NO NO /\JO
-18 -Ii -,s -
VI'
37
TANK INSTALLATION CHECKLIST
INSTALLING TANKS (See Sections 5 and 7) TANK#1 TANK#2 I TANK#J TANK#4 !
Record tank diameter measurement #1 (before install ati on) , zq 'IZ'' 1iq~• 12'1 W IZ<.f~
Record fina l backfill bedding depth under tank-inches or centi meters lt'-1 S'' 1-Z:'~" /'Z .... , S-'' ,2~,s ..
Record fi n.al tank spacing between tanks~ inches or centi meters '36" 3'" ~·· ~6 ,,
Record fina l tank spacing from tank endcap to excavation walls -i nches ?,6~' 3(" 3t" 36"
or centim~ters
If appli cable, _dead men used-fac tory-supplied or other ~rt ,8-}tty .ficferl fo.C/dt,Y
If appli cabfe, anchoring hardware -factory-suppli ed or other ~Jory fi.t/c(y p=-..«J(j ~ '(JI ,~-,
Record diameter measurement #2 (after straps are installed) 1.'2'1 ?z1t /ZL/1/f1t tZ'l lJ''' !VI 1ff"
Subtract diameter measurement #2 from #1 and record 0 0 0 0
Deflection measurement meets Table 1-6 requi rements -yes or no ; i~ y~ ,Ye.~ YeJ
Voids under tank between ribs and under domes filled with backfill Yes YeJ ){5 Ve5 and tamped -yes or no
Backfil l placement and compaction meet req ui rements -yes or no x-e' .Ve< Y~s ,YeJ
Piping connections meet requirements-yes or no Ye< }t{ Ye< ¼5 ., ✓ r
Fittings and othe r metal components are coated for corrosion Yes Vt.S ¾J ,YcJ protection -yes or no
Record diameter measurement #3 (after backfi ll ing to top of tank is ". · 1iLJ 'lz.•l ( l-'i j/y I\ /2'( ljfl rZLf 1,,r 1r complete)
Subtract diameter measurement #3 from #1 and record ~ 0 D 0
Deflection measurement meets Table 1-6 requirements-ye.s or no ye_~ Y~<; Yt<. Yr (
r Aj() NO Tank was ballasted prior to bring ing backfill to top of tank-yes or no /\JO · AJO
After backfilling is brought to top of tank (See Sections 5, 6 and 8) ,
Tank was bal lasted after bringing backfill to top of tank -yes or no y-c ~ Yt5 Yes ~f
Postinstallation tests were conducted for pressure-testable tanks -yes Ytj ye:5 ,Ve5 ye5 or no
If applicable, optional hydrostatic test was performed -yes or no ye_~ ,v'e f ~5 ~>
If applicable, cont ai nment sump test was successful -yes or no yr_J '/tS Yes Yes
Record final depth of backfill over tank -give in inches or centimeters qs•~so ,, ·45! 50 ,, f./ s•• -50 I I q5:: ~I\
Record diameter measurement #4 (after backfil li ng is brought to
1'2~ '/z"·L f Z'( J/f11 I ?-t,,/ 7//'c rz~, 7A''' subgrade)
Subract diameter measurement #4 from #1 and record D 0 tJ 0
Final deflection measurement meets requi rements ofTable 1-6 -yes
Y~s ie5 '}ej jeJ or no '
If applicable, type of surface pad used -concrete or asphalt U,V\Cv-U(_ {J;Vlvvt/e ~'(tl)e_ (CJ.,t(xt//e..
If applicable, thi ckness of surface pad used -give in inches or 6 ,l 6 ll 6 IC {"'
centi meters and note which type
If applicable, reco rd monitoring fluid level when backfillin g & top slab ----
install atio n are complete
38 XERXES®
BY SHAWCOR
I
s r, "'" '..,
\..... ~
:f'-~j K
uJ, ,\.
SITE SKETCH (Indicate specifics of tank installation.)
\J,)
\
-~ UI ,c, I~ ,,. ..
IJ ('
..)
'
,,, ('\ r ~ 1-.:=•
, .
,1,1 J
~ ~~ , ,
q r11t ~,
~ u '-,/ ,t~
I~~ f(
\}I, 11,,o ..
-
~ -·
VERIFYING SIGNATURES , ,
CONTRACTOR
'
111-r1 --,-
1J
TANK INSTALLATION CHECKLIST
ADDITIONAL NOTES
Note any variations and/or deviations from
instructions (and attach written authorizations):
TANK OWNER/REPRESENTATIVE
I verify that this information is a true record of the installation of the tanks I verify that this information is a true record of the installat ion of the tanks
listed here. listed here,'and t hat I have received a copy of the Installation Manual
and t his Tank Instal latio n Checkli st.
Name:
Email:
Address:
Signature:
Date: Date:
TO INSTALLER: After tank installation, deliver the Installation Manual with the completed Tank Installation Checkli stto t he tank owner. Retain a copy of
each for your records.
TO OWNER: After instal lation, retain the limited warranty, the Installation Manual and completed Tank Installation Checklist for future reference and to
facilitate any warranty claim.
XERXES® 39
BY SHAWCOR