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Site Address: Date of Testing(Seruicing: <br /> F. Ira-Tank Gangiag/SIR Equipment: Check this bort if tank gauging is used only for inventory canrol. <br /> ❑ Ch=k this box if no tank ganging or SIR equipment is installed <br /> This section must be completed if in-tank gauging equipment is used to perform leak detection monitoring. <br /> Cole tete the following checklist: <br /> ❑ Yes ❑ No' 1 Has all input wiring been inspected for proper entry and termination, including testing for ground faults? <br /> ❑ Yes ❑ No' I Were all tank gauging probes vrsmatly inspected for damage and residue buildup? <br /> ❑ Yes ❑ Noy Was accuracy of system product level readings rested? <br /> ❑ Yes 10 No* 1 Was accuracy of system water level readings tested? <br /> ❑ Yes 1 ❑ No' Were all probes reinstalled properly' <br /> Yes I ❑ No' Were all items on the equmment mamdacirner's maintenance checkfist completed? <br /> In the Section H. below.describe hum and when these deficiencies were or will he zorrected. <br /> G. Line Leak Detectors (LLD): ❑ Check this box,f LL—s are not oasratlea. <br /> CoamAete the following checklist: <br /> Yes ❑ No" : For equipment .=a-"ip or annual Ampmem tion, was a leak simulated to verify LLD performance' <br /> ❑ N/A (Check all that apply) Simulated leak rate: (I g.p.h.', ❑0.1 g.p.h."; ❑0.2 g p.h. <br /> Notes: 1. Required for equipment start-up certification aid annual certific adon. <br /> 2. Umiess mandated by local agency,xrification required only for electronic LLD start-sup. <br /> ❑ No' Were all LLDs confirmed operational amt accurate within motlatory requirements? <br /> ❑ No* Was the testing apparmus property calibrated? <br /> Yes ❑ No' For mechanical LLDs,does the LLD restrict product flow if it detects a leak? <br /> ❑ NIA <br /> ❑ Yes ❑ )W For dectrom LLDs,does the turbine automatically shut off if the LLD detects a leak? <br /> A <br /> ❑ Yes ❑ �(o" For esectromc LLDs. does the nrbirre automatically stint if any portion the monitoring syen is disabled <br /> N/A or disconnected? <br /> ❑ Yes ❑ thO For electronic LLDs, does the turbine automatically shut off if any portion of the monitoring system <br /> Cr�NIA malfhuctions or fails a tet? <br /> ❑ Y ❑ For c lectrondc LLDs, have all accessible wiring connecum as been visually inspected? <br /> Gd'N/A <br /> Yes ❑ Not Were all stems on the Nutriment marruGa:mrer*e waimenance cbA zcklist,:empteted? <br /> In the Section H,below.describe how and when these deficiencies were or will he corrected. <br /> H. Comments. <br /> Page 3 of 3 03/01 <br />