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Monitoring System Certification-Page 3 of 3 REcMED NOV 2 2 2016 Site Address: 610 S.Cherokee Ln. Date of Testing/Servicing: 10/25/16 FF \/ NMENTAL HEAL:I rl F. In-Tank Gauging/SIR Equipment: ® ChecktA(s yl only for inventory control. ❑ Check this box i ink gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Comolete the following checklist: ❑ Yes ❑ No* Has all input wiring been inspected for proper entry and termination,including testing for ground faults? ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? ❑ Yes O No* Was accuracy of system product level readings tested? ❑ Yes ❑ No* Was accuracy of system water level readings tested? ❑ Yes ❑ No* Were all probes reinstalled properly? ❑ Yes 0 No* Were all items on the equipment manufacturer's maintenance checklist completed? *In Section H below,describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors(LLD): ❑ Check this box if LLD's are not installed. Complete the following checklist: ® Yes ❑ No* For equipment start-up or annual equipment certification was a leak simulated to verify LLD performance? ❑ N/A (Check all that apply) Simulated leak rate: ® 3 g.p.h.(1.); ❑ 0.1 g.p.h.(2.); 0 02 g.p.h.(2.). Notes: 1. Required for equipment start-up certification and annual certification. 2. Unless mandated by local agency,rertification required only for electronic LLD start-up. 2 Yes ❑ No* Were all LLD's confirmed operational and accurate within regulatory requirements? 0 Yes ❑ No* Was the testing apparatus properly calibrated? ® Yes ❑ No* For mechanical LLD's,does the LLD restrict product flow if it detects a leak? ❑ N/A ❑ Yes ❑ No* For electronic LLD's,does the turbine automatically shut off if the LLD detects a leak? ® NIA ❑ Yes ❑ No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system is disabled a N/A or disconnected? n Yes ❑ No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system 2 N/A malfunctions or fails a test? ❑ Yes 11 No* For electronic LLD's,have all accessible wiring connections been visually inspected? ® N/A ® Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? "In Section H below,describe how and when these deficiencies were or will be corrected. H. Comments: