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04/14/2004 07:49 4089710135 SSS INC PAGE 04 <br /> Monitoring System Certification- Pa•of 3 <br /> Site Address:, 1011 N. Main St. 6% Louise _ Date of7estutg/Servicing; 3122104 <br /> F. In-Tank Gauging/ SIIi Equipment: ® Check this box if tank gauging is used only for inventory control. <br /> D 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 /> Com tete the following checklist: <br /> 0 Yes ONO* Has all input wiring been inspected for proper entry and temvnation,including testing for ground faults? <br /> 0 Yes 0 No* Were all tank gauging probes visually inspected for damage and residue buildup? <br /> 17 Yes 0 No* Was accuracy of system product level readings tested? <br /> 0 Yes ❑No* Was accuracy of system water level readings tested'? <br /> 0 Yes 0 No* Were all probes reinstalled properly? <br /> Dyes ❑ No* Were all items on the equipment manufacturer's maintenance checklist completed? <br /> *In Section H below,describe how and when these deficiencies were or will be corrected. <br /> C. Tine Leak I)etectors(I.LD): D Check this box if LLD's are not installed. <br /> Com rete the following checklist: <br /> 11 Yes 0 No* For equipment start-up or amoral equipment certification was a leak simulated to verify LLD perforrmuce? <br /> D N/A (Check all that app1v) Simulated leak reatc: 2 3 g.p.h.(1.); D 0.1 g.p.h. (2.); 0 0.2 g.p.h.(2.). <br /> Notes-. 1 R rqu;mel fur equipment start-up certification and annual certification. <br /> 2. Unless mandated by local agency,certification required only for electronic LLD start-up. <br /> 0 Yes 0 No* Were all LLD's confirmed o erational and accurate within regulatory re uirements? <br /> 3 Yes ❑ No" Was the testin a aratus properly calibrated'? <br /> ❑Yes 0 No* For mechanical LLD's,does the LLD restrict product flow if it detects a leak? <br /> ®N/A <br /> ®Yes D No* For electronic LLD's,does the turbine automatically shut off if the LLD detects a leak? <br /> D N/A <br /> a Yes Cl No* For electronic LLD's,does the turbine automatically shut off if any portion of the monitoring system is disabled <br /> 0 N/A or disconnected? <br /> X Yes tJ No* P or electronic LLD's,does the turbine automatically shut oft'if any portion of the monitoring system <br /> 0 N/A malfunctions or fails a test'? <br /> ®Yes n No* For eleerrnnic I d.D's,have all acce.ssible wiring connections been visually inspected? <br /> ❑ NIA <br /> ®Yes n No* Were all it on the equipment manufacturer's maintenance checklist completed? <br /> "In Section H below,describe how and when these deficiencies were or will be corrected. <br /> H. Comments: <br />