DERR-2025-002316

�-Facility Name:
Address:
City, State, Zip Code:
Facility I.D. #:
Testing Company:
LIQUID SENSOR FUNCTIONALITY TESTING
Owner:
Address:
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Phone#:
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This procedure is to determine whether liquid sensors located in the interstitial space of UST systems are able to detect the presence of water and fuel. See PEI/RP1200
Section 8.3 for the test procedure.
Sensor Location
Product Stored
□Discriminating □ Discriminating □ Discriminating □ Discriminating □ Discriminating □ Discriminating D Discriminating
Type of Sensor □Non-discrimi-D Non-discrimi-□Non-discrimi-□Non-discrimi-□ Non-discrimi-□ Non-discrimi-D Non-discrimi-
nating nating nating nating nating nating nating
Test Liquid □Water D Water □Water □Water □Water □Water D Water □Product D Product □Product □Product □Product □Product D Product
Is the ATG console clear of any active
or recurring warnings or alarms
regarding the leak sensor? If the □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
sensor is in alarm and functioning,
indicate why.
Is the sensor alarm circuit □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No operational?
Has sensor been inspected and in □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No good operating condition?
When placed in the test liquid, does □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No the sensor trigger an alarm?
When an alarm is triggered, is the
sensor properly identified on the ATG □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No □Yes □No
console?
Any "No" answers indicates the sensor fails the test.
Test Results □Pass □Fail □Pass □ Fail □Pass □Fail □Pass □Fail □Pass □Fail □Pass □Fail □Pass □Fail
Comments:
Tester's Name (print) ,, Tester's Signature
-0m:::::::0 -0 ~ 0 0 I �
I.O