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Njonitcring System Certification <br /> nDate of 1'estinglServicing: <br /> Site Address: kXy4 9 <br /> F. In-Tank Gauging Slit Equipment• ❑15,eck this box if tank gauging is used only for inventory control. <br /> ' Q Check this box if no tank gauging or SIR equipment is installed. <br /> This section must be completed if in-tank g-Ulging equipment is used to perform leak detection monitoring. <br /> Complete the following checklist: <br /> Cl Yes El No* Has all input wiring been inspected for proper entry and termination, including testing far ground faults? <br /> ❑ Yes ❑ No* Were all tank gauging probes visually inspected for damage and residue buildup? <br /> ❑ Yes ❑ No* Was accuracy of system product level readings tested? <br /> ❑ Yes ❑ No* Was accuracy of system water level readings tested? <br /> ❑ Yes G No* Were all probes reinstalled properly? <br /> ❑ Yes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> * In the Section H, below,describe how and ►vhcn these deficiencies everc or will be corrected. <br /> G. Line Leak Detectors (LLD): ❑ Check this box if MDs are not installed. <br /> Complete the following checklist: <br /> El Yes ❑ No* For equipment start-up or annual equipment ceer fication, was a leak simulated to verify LLD performance? <br /> Cl NIA (Check all Mat apply) Simulated leak rate: 3 g.p•h•; ❑ 0.1 g-p•li ; ❑ 0.2 g.p.h. <br /> 13 Yes No* Were all LLDs canfinned operational and accurate within regulatory requirements? <br /> Yes ❑ No* Was the testing apparatus properly calibrated? <br /> ❑ Yes No* For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> NIA <br /> e automatically s <br /> ❑ Yes 13 No* For electronic LLDs,does the turbishut off if the LLD detects a leak? <br /> C <br /> ❑ Yes El NO For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> Lp` /A or disconnected? <br /> ❑�0* For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system <br /> o N/A malfunctions or fails a test?❑ No* For electronic LLDs, have all accessible wiring connections been visually inspected? <br /> 0 l/A <br /> ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> In the Section H,below, describe how and when these deficiencies were or will be corrected. <br /> H. Comments: 1 i/ V IJ <br /> r <br /> Page 3 of 3 {15100 <br />