DERR-2025-001510

FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE SOLUTIONS
ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT

P.O. BOX 3360
DES MOINES, IA 50316

4140 E. 14TH STREET
DES MOINES, IA 50313
PHONE: [phone]
CORPORATE HEADQUARTERS

WWW.SENECACO.COM
STORE.SENECACO.COM
Seneca Account Rep:
Phone:
Date of Test:
Scope of Work:
Seneca Job #
Customer PO #
Technician:
Certification:(see test reports attached)
Testing Summary
Test Summary Description Component Tested Date Tested Result
Customer Information
Name:
Street Address:
City:
State:
Zip:
Contact:
Phone Number:
Site Information
Site Name:
Testing Summary
Street Address:
City:
State:
Zip:
Facility No.
Field Notes
4140 E. 14TH STREET
DES MOINES, IA 50313
PHONE: [phone]
CORPORATE HE

ADQUARTERS
P.O. BOX 3360
DES MOINES, IA 50316
WWW.SENECACO.COM
STORE.SENECACO.COM
Testing Summary
Testing Summary
FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE SOLUTIONS
ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT
Inspection Date:
Site Name:
Address:
City/State/Zip:
Tank Number 1 2 3 4 5 6 7 8
Product:
Equipment Manufacturer:
List Type of Equipment (automatic, high level alarm, ball float):
Drop tube removed from tank?
Drop tube and float devices are free of debris?
Float moved freely and poppet moves into flow path?
Bypass valve in the drop tube (if present) is open and free blockage?
Flapper is adjusted to shut off flow at 95% capacity?
Electronic device and probe are opening properly?
Alarm activates at 90% capacity or within one minutes of overfill?
Alarm can be heard from where the tank is fueled?
Tank Top fittings are vapor tight and leak free?
Ball float cage free of debris?
Ball is free of holes and cracks and moves freely in cage?
Vent hole in pipe is open and near top of tank?
Ball float pipe is proper length to restrict flow at 90% capacity?
Pass Pass Pass Pass Pass Pass Pass PasInspection Results (select one)
(No to any question indicates a test failure)Fail Fail Fail Fail Fail Fail Fail Fail
Inspection Company:
Technician:
Over Fill Equipment Inspection
Automatic Shutoff Device Inspection/Tested per Manufacturer Guidelines
Over Fill Alarm Inspection/Tested per Manufactuer Guidelines
Ball Float Valve Inspection/Tested per Manufacturer Guidelines
Comments:
Seneca Companies, Inc. follows the PEI RP 1200 standard for certification of overfill devices
4140 E. 14TH STREET
DES MOINES, IA 50313
PHONE: [phone]
CORPORATE HEADQUARTERS
P.O. BOX 3360
DES MOINES, IA 50316
WWW.SENECACO.COM
STORE.SENECACO.COM
FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE SOLUTIONS
ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT
FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE SOLUTIONS
ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT
OPV 3
FUEL SYSTEMS | GENERAL CONTRACTING | ENVIRONMENTAL SERVICES | WASTE
SOLUTION ENERGY SOLUTIONS | AUTOMOTIVE & COMMERCIAL EQUIPMENT

Site Name: Site Address: -ob :
City: State: =ip: Date:
Scope of Work:
Arrival Time to Site: Departure Time from Site:
DP leak/Sump/SB Cathodic Protection MC/LLD Vapor Recovery Calibration
Technician: Post-Test SiJnature:
**By signing below, you confirm that the items listed above have been visually verified by you.
Site Contact: Post-Test SiJnature:
Inspector on site" Yes No If yes, please Jive name:
Service TestinJ
A.All
B.TestinJ
Yes No
Notes:
All shear valves have been set to open (if applicable).
TestinJ and Service Environmental Checklist
Dispatch Type:
4140 E. 14TH STREET
DES MOINES, IA 50313
PHONE: [phone]
CORPORATE HEADQUARTERS
P.O. BOX 3360
DES MOINES, IA 50316
WWW.SENECACO.COM
STORE.SENECACO.COM
Testers must upload a copy of this completed form with reports/photos and email to Mark Shirley and Emma Petrowitz.