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0nitoring System Certification 1191 <br /> Site Address: 2725 COUNTRY CLUB BLVD Date of Testing/Service: 04/0212009 <br /> F. In-Tank Gauging 1 SIR Equipment FRI <br /> Check this box if tank gauging is used only for inventory control. <br /> ❑ Check this box if no tank gauging or SIR equipment is installed. <br /> Check this box if no tank gauging or SIR equipment is installed. <br /> This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. <br /> Complete the following checklist: <br /> ❑Yes R• Has all input wiring been inspected for proper entry and termination,including testing for ground faults? <br /> ❑Yes ` Were all tank gauging probes visually inspected for damage and residuebuildup? <br /> ❑Yes • Was accuracy of system product leve#readings tested? <br /> ❑Yes ❑No` Was accuracy of system water level readings tested? <br /> ❑Yes ❑No. Were all probes reinstalled properly? <br /> ❑Yes ❑No` Were ail items on the equipment manufacturers'maintenance checklist completed? <br /> 'In the Section H,below,describe how and when these deficiencies were or will be corrected. <br /> G. Line Leak Detectors (LLD) : ❑ Check this box if LLDs are not installed. <br /> Complete the following checklist: <br /> � For equipment start-up or annual equipment certification,was a leak simulated to verify LLD performance? <br /> LJ Yes ❑No ❑NIA Check all that apply)Simulated leak rate: Q 3 g.p.h LJ 0.1 g.p.h ❑0.2 g.p.h <br /> X Yes ❑No` Were all LLDs confirmed operational and accurate within regulatory requirements? <br /> X Yes ❑No• Was the testing apparatus properly calibrated? <br /> ❑X Yes ❑Na• ❑NIA For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> 0 Yes ❑No' Ej NIA For electronic LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> Q N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system is disabled or disconnected? <br /> F-1 Yes ❑No• <br /> ❑Yes []No` ❑N/A For electronic LLDs,does the turbine automatically shut off if any portion of the monitoring system malfunctions or fails a test? <br /> ❑Yes ❑Na• Q N/A For electronic LLDs,have all accessible wiring connections been visually inspected? <br /> 0 Yes I[:]No Were all items on the equipment manufacturers'maintenance checklist completed? <br /> In the Section H,below,describe how and when these deficiencies were or will be corrected. <br /> H. Comments: <br /> Page 3 of 3 Based on CA form dated 03/01 <br />