DERR-2024-005954

Facility Name: Owner:
Address: Address:
City, State, Zip Code: City, State, Zip Code:
Facility I.D. #: Phone #:
Testing Company: Phone #: Date:
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
Type of Sensor
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Discriminating
Non-discrimi-
nating
Test Liquid Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Water
Product
Is the ATG console clear of any active
or recurring warnings or alarms
regarding the leak sensor? If the
sensor is in alarm and functioning,
indicate why.
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Is the sensor alarm circuit
operational? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Has sensor been inspected and in
good operating condition? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
When placed in the test liquid, does
the sensor trigger an alarm? Yes No Yes No Yes No Yes No Yes No Yes No Yes No
When an alarm is triggered, is the
sensor properly identified on the ATG
console?
Yes No Yes No Yes No Yes No Yes No Yes No Yes No
Any “No” answers indicates the sensor fails the test.
Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail Pass Fail
Tester’s Name (print) ___________________________________ Tester’s Signature _______________________________________________