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Monitoring Svstem Certification-Pas of 3 Site Address: 1071 N.Main St. Date of Testing/Servicing: 3-7-2001 F. In-Tank Gauging f SIR Equipment: N1 Check this box if tank gauging is used only for inventory control. ❑ Check this box if no tank gauging or SIR equipment is installed. This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. Com lete the follo ing checklist: ❑ Yes 0 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 ❑ 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 L3No* Were all items on the equipment manufacturer's maintenance checklist completed? * In the Section H,below,describe how and when these deficiencies were or will be corrected. G. Line Leak Detectors (LLD): ❑ Check this box if LLDs are not installed. COm late the ing checklist: Hi Yes Ll No* For equipment start-up or annual equipment certification, was a leak simulated to verify LLD performance'? ❑ NIA (Check all that apply) Simulated leak rate: IT 3 g.p.h.'; ❑ 0.1 g.p.h.?; ❑ 0.2 g.p.h.` Notes: 1. Required for equipment start-up certification and annual certification. 2. Unless mandated by local agency,certification required only for electronic LLD start-up. ® Yes ❑ No* Were all LLDs confirmed operational and accurate within regulatory requirements? El Yes ❑ No* Was the testing apparatus properly calibrated? ❑ Yes ❑ No* For mechanical LLDs,does the LLD restrict product flow if it detects a leak? Hl NIA O Yes ❑ No* For electronic LLDs, does the turbine automatically shut off if the LLD detects a leak? FCINo* A � Yes * For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system is disabled A or disconnected? ® Yes For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system A malfunctions or fails a test? 0 Yes ❑ No* For electronic LLDs,have all accessible wiring connections been visually inspected? ❑ NIA ❑x Yes Ll No* Were all items on the equipment manufacturer's maintenance checklist completed? *In the Section H below,describe how and when these deficiencies were or will be corrected. H. Comments: UN-036-516 http:llwww.unidocs.org Rev.08/22/00